Activist-driven transgender research methods are reckless and will lead to harms

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The current field of transgender medicine is like a reckless, “Wild West” free-for-all in which activist clinicians run small, terribly biased observational studies and then “spin” narratives that seem to “confirm” benefit. Based on these studies, other researchers go through the motions of conducting systematic reviews and developing evidence-based guidelines. The motions they go through, however, are only a masquerade of evidence-free smoke and mirrors, just for show. These practices will undoubtedly lead to harms.

In the past decade there has been a sharp increase in the numbers of people presenting to care with gender dysphoria [1-4]. The growth has been especially marked in adolescents and young adults [1-4]. Reports from clinics around the world have also noted an inversion of the expected sex ratio, and gender dysphoria is now far more commonly seen in young female patients than it is in young males [1-5]. There is evidence that most gender dysphoria in young people may be part of a social contagion [6].

The treatment model currently in vogue among clinicians who care for patients with gender dysphoria, including child patients, is called affirmative care [7-11]. In the “affirmative” regime, no-one is allowed to question whether any human being was ever born with an innate, opposite-sex “gender identity,” and of course there is no scientific evidence that anyone ever was. If a female patient says she “identifies as a man,” she must in fact be a man. Doctors then “affirm” such patients into a treatment regimen that normally includes a lifetime taking opposite-sex hormones, as well as receiving major surgeries [12]. The slow and careful “transsexual” gatekeeping process of previous decades, including a year or two spent “living as” a member of the opposite sex, before any hormones or surgery were offered, is long gone [12-13]. In the United States, patients may be prescribed opposite-sex hormones at their first clinical visit [14]. In Los Angeles, girls (who believe they are boys) as young as age 13 are having their healthy breasts amputated [15].

Given the adoption of “affirmative care” practices by many physicians, psychologists, and professional medical societies [8] – practices that confer “patient for life” status on healthy young people – one would expect there to be rather strong evidence of benefit for these drastic interventions, as well as for harms if they are not offered. This is not the case at all.

The transgender intervention literature is wholly observational and almost entirely without controls. It is a miasma of selection bias, unmeasured confounding and missing data. Many transgender research studies in the past few decades have been conducted by activist researchers who seem deeply committed to “proving” the benefits of transgender interventions, no matter how speculative or tendentious the research question. As I will show later in this Commentary, there may be substantial “spin” in reports of such studies, portraying study methods and outcomes favorably and minimizing (or not reporting) adverse events and harms. Convenience sample data are used to make solemn pronouncements about suicide risk [16]. In long-term follow-up of patients after “sex reassignment” surgery, it is common to find that one-quarter, one-third, one-half or even larger proportions of patients have simply disappeared, with investigators failing to account adequately for them [17-18].  There is good reason to be highly skeptical of the reported benefits of any transgender intervention. One cannot draw firm conclusions from this evidence, except to conclude that it is abysmally poor evidence. The reasons why investigators do their work so badly are obscure. This laissez-faire attitude also seems to have trickled down into secondary analyses of transgender research.

For example, in 2017, anonymous authors at Cornell University produced a document titled “What does the scholarly research say about the effect of gender transition on transgender well-being?” [19]. This document purports to be a “systematic literature review,” but is not one. It pretends to use a rigorous systematic review process to create the impression that transgender interventions are safe and effective. Because anecdotal reports suggest that many people who do not know better are taking the Cornell review’s spurious “findings” at face value, I evaluated the methods and reporting of that document.

METHODS

I conduct my analysis of the Cornell document with two instruments commonly used to critically appraise systematic reviews. “A Measurement Tool to Assess Systematic Reviews” version 2 (AMSTAR 2) is a 16-item checklist used to assess whether a systematic review’s methods are unbiased, comprehensive and indeed systematic [20]. The “Preferred Reporting Items for Systematic Reviews and Meta-Analyses” (PRISMA) checklist includes 27 items and is designed to improve consistency and transparency in the reporting of systematic review methods [21]. The instruments are complementary to one another.

While the purpose of AMSTAR 2 is to assess the quality and rigor of a systematic review’s methods, the PRISMA checklist is designed to help systematic review authors to report their methods and findings consistently and transparently. It is also intended for the use of others in evaluating whether a given systematic review reports its methods consistently and transparently. Many peer-reviewed scientific journals now require that submitted systematic reviews be accompanied be a completed PRISMA checklist, with all items noted as having been done.

Following my assessment with these instruments, I enumerate the Cornell review’s other serious problems in a narrative discussion. I then discuss another attempt by clinicians of transgender research to “hijack” evidence-based medicine [22] by merely pretending to follow evidence-based methods. Finally, using an example from the recent transgender literature, I show the biased methods used and spurious outcomes reported by activist investigators of primary studies.

RESULTS

AMSTAR 2: The Cornell document fared poorly under examination with the AMSTAR 2 instrument. All questions answered with “No” or “Not reported” would optimally have been answered with “Yes.” This review’s methods appear to have been grossly inadequate. Please see the Appendix for details.

PRISMA checklist: The authors of the Cornell review failed to meet nearly every criterion of the PRISMA checklist. All items denoted as “Not done” would optimally have been answered with “Done.” Reporting of this review’s methods and findings was very sloppy. Indeed, the review could hardly have been reported with less rigor. Please see the Appendix for details.

DISCUSSION

I evaluated the Cornell review in terms of its methods and its reporting of these methods. The review fared very badly on both accounts. From the perspective of evidence-based medicine and scientific rigor, the review failed completely in meeting even the most meagre standards.

I have seen many bad systematic reviews published, but none have been so far off the mark as this Cornell review. Perhaps it is not surprising that this review’s authors chose to remain anonymous. Had their names been associated with this document, it could have had a negative impact on their careers. What is surprising is that despite there being plenty of guidance in systematic review methods available online, for free, with workshops even offered at their own university, these authors chose simply to “go through the motions.” They even mentioned PRISMA at the beginning of their “Methods” section, but then conducted and reported their review in an irresponsible ad hoc manner.

Although PRISMA is intended to guide reporting of systematic reviews, and not serve as a “roadmap” to conducting them, the authors had the PRISMA guidance in hand. Surely, they must have seen the long list of things they were failing to do. One or two more clicks on the internet, and they might have found some proper guidance in methods for conducting an adequate systematic review. Instead, these authors cloaked themselves in PRISMA’s name and then did as they pleased.

The Cornell review’s research question was vague and very poorly formulated, almost as though the authors were looking into a crystal ball when they developed it: “What does the scholarly research say about the effect of gender transition on transgender well-being?” The inclusion criteria for their review were so permissive that eligible reports could be on any topic relevant to transgender “transition,” or as I would define it, the medicalized performance of opposite-sex stereotypes. Studies of any design were eligible, even those without comparator conditions and qualitative studies. They need only to have reflected some intervention recommended by the World Professional Association for Transgender Health (WPATH) [23]. Reported outcomes could be any expression of current feelings, self-reported quality of life, relationship satisfaction and other measures – and the authors explicitly do not require a minimum follow-up period. The authors’ choice of “quality of life” or “well-being” as key outcomes meant that they would likely have excluded studies reporting depression, suicide attempts and completed suicide, but that did not formally or informally assess “quality of life” or “well-being” as such.

Considering the poor methodological quality of the transgender literature – and especially considering that they were, after all, trying to conduct a systematic review – it is bizarre that the authors did not consider it necessary to assess the risk of bias in each study.

Did these authors ever intend to be objective in their work? I doubt it. They did not even pay attention to what they were doing.  We can see this in the “objectives” of the Cornell authors’ review, which may have been written by a computer, or by someone who cared very little about communicating clearly and transparently with the review’s readers.

Our objective was to aggregate scholarship that adds in some way to the world’s knowledge about the policy issue in question. Adding to knowledge does not necessarily mean drawing new conclusions but can include strengthening existing knowledge by corroborating what prior studies have shown. Our purpose is not to pick and choose research that endorses a particular policy view but to include the broadest reasonable range of relevant scholarship so that users may both obtain an overview of the present state of scholarly knowledge on topics that are currently matters of public debate, and further examine that research directly if desired. We recognize that the peer-review process is imperfect but we operate on the principle that it represents the best method we have for holding research accountable to both good faith and sound methodologies. [19]

It is rare to see such stilted, uncomfortable, meaningless writing. It is like writing that somehow materialized at a séance.

The next passage mentions a “strict set of criteria for selecting studies based on credibility, relevance and usefulness,” but these criteria are nowhere reported. The passage then seems to ramble on incoherently, and it appears that at least some of the passage was copied and pasted from an unrelated project’s document.

The Cornell authors do not report conducting any sort of analysis. They do not bother to assess bias risk. They do not even put together a table with study characteristics, much less a list of excluded studies, with reasons for exclusion. All outcomes reported favorably in their included studies are affirmed without question as solid scientific evidence.

These are the first four “findings” of the Cornell document, out of eight in total:

  1. The scholarly literature makes clear that gender transition is effective in treating gender dysphoria and can significantly improve the well-being of transgender individuals.
  2. Among the positive outcomes of gender transition and related medical treatments for transgender individuals are improved quality of life, greater relationship satisfaction, higher self-esteem and confidence, and reductions in anxiety, depression, suicidality, and substance use.
  3. The positive impact of gender transition on transgender well-being has grown considerably in recent years, as both surgical techniques and social support have improved.
  4. Regrets following gender transition are extremely rare and have become even rarer as both surgical techniques and social support have improved. Pooling data from numerous studies demonstrates a regret rate ranging from .3 percent to 3.8 percent. Regrets are most likely to result from a lack of social support after transition or poor surgical outcomes using older techniques.

These “findings” are absurdly optimistic and grossly exceed the limits of what the evidence shows. Their statements characterizing this evidence are made without the slightest caution. The authors pretend to be certain of the benefit in all outcomes of transgender interventions, when in fact these outcomes are highly uncertain. Written in a quasi-authoritative tone, the “findings” seem designed to encourage people in the ruminative phase of gender dysphoria to justify their transgender “transition.” People who have no means to assess the value of this evidence are likely to be led astray by the review’s enthusiastic statements.

In view of the uncertain outcomes, the authors missed their chance to do something useful. One excellent thing about rigorously-conducted systematic reviews on topics in which the methodologic quality of primary literature is very poor, with large gaps in what is known about long-term outcomes, is that the review can specifically point out these deficiencies and evidence gaps, both to suggest caution to users of systematic reviews and to guide the planning and conduct of future primary studies. Transgender research could only have benefited from this.

Faking the GRADE.  “Going through the motions” is apparently not rare in analyses by activist researchers of transgenderism. The University of California, San Francisco (UCSF) is home to the Center of Excellence for Transgender Health. In 2016, this entity published a document titled “Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People” [24]. The document was edited by Dr. Madeline Deutsch, an associate professor of family and community medicine, who also identifies as transgender. In the first chapter, “Grading the evidence,” the authors claim they will use the GRADE methodology to develop their guideline’s recommendations [25]. GRADE is the “global standard” methodology used to assess the certainty of evidence from rigorous, up-to-date systematic reviews, and based on that evidence, to develop health recommendations [26-28].

The UCSF authors do cite an appropriate article to provide general information about GRADE [29]. As the authors describe their process, however, it becomes clear that they have done no systematic reviews and are completely unfamiliar with GRADE.

Selected recommendations in these Guidelines have been graded using adaptation of some components of the GRADE scoring system, with the addition of two additional domains to describe details of the research which underlies the recommendation, as well as the population(s) in which such research was conducted. Each graded recommendation will include mention of the population(s) in which research was conducted (transgender (T), non-transgender (NT), or both (T/NT) (Table 1); an indication of, among all sources informing that particular recommendation, the strongest form of underlying evidence (meta-analyses, randomized trials, observational studies, expert opinion) (Table 2). Lastly, an overall grading of the strength of recommendation is made (strong, moderate, weak) which is based on the above criteria as well as strength of the consensus recommendation as determined by expert opinion interpretation of available data (Table 3.). [25]

The methods proposed by the UCSF authors, a word-salad of empty terms, have nothing at all to do with GRADE. It was just name-dropping. Did they really think no-one would notice? This blather might fool readers who themselves are unfamiliar with GRADE but could not possibly fool anyone who has actually used these methods.

The guidance in the UCSF document is astonishing. In a chapter called “Initiating hormone therapy,” written by Deutsch, we find that almost anyone, even a naturopathic provider (!) is eligible to start a patient on a lifelong drug regimen, one with significant risk of harm [30-33]:

Prescribing gender affirming hormones is well within the scope of a range of medical providers, including primary care physicians, obstetricians-gynecologists, and endocrinologists, advanced practice nurses, and physician assistants. Depending on the practice setting and jurisdiction, other providers with prescriptive rights (naturopathic providers, nurse midwives) may also be appropriate to prescribe and manage this care. [14]

A terrible cohort. Let us examine the kinds of problems that systematic reviewers who are serious about their work may find in “gender-affirming” primary studies.

A 2018 paper by Olson-Kennedy and colleagues [15] reports on a cohort of 68 adolescent and young adult women, self-diagnosed as transgender “men,” whom Olson-Kennedy had referred to surgeons for bilateral radical mastectomy (“top surgery”).

olson-1Thirty-one (46%) young women were age ≤ 17 years; 16 (24%) were age ≤ 15 years. Two were 13 years old. The outcome of “regret” was assessed in a follow-up period of “less than one year” to five years, with outcomes for 59 (87%) women assessed at one year or less. Olson-Kennedy and colleagues report this in a table but do not otherwise mention it or seem to think that this might not be appropriate. Twenty-eight (41%) young women had only begun their medicalized transgender experience very recently, starting a testosterone regimen within the preceding two years. Six (9%) young women had been on testosterone for less than six months; at least one young woman began taking testosterone less than one month prior to surgery. Investigators did not obtain data from 26 (28%) patients lost to follow-up, a proportion that in most areas of clinical care would be considered unacceptable.

Most patients suffered at least one post-surgical complication. These included temporary loss of nipple sensation (59%); loss of sensation in other areas (41%); long-term loss of nipple sensation (32%); excessive scarring (15%); postoperative hematoma (10%); complications from anesthesia (7%); and other complications. Notwithstanding these problems, Olson-Kennedy and colleagues sought to minimize them by saying that “[S]erious complications were rare” [15].

Although some patients feel regret very soon after transgender surgery, it commonly takes several years, often 10 years or more, for patients to realize they have made a mistake [18, 33]. It was thus far too soon to obtain a meaningful estimate of “regret” from these patients. There was one acknowledged case of regret at that early follow-up point. Even so, Olson-Kennedy and colleagues spin their results, declaring in the article’s abstract that there was “close to zero” regret among the patients [15]. Given the irreversible nature of this drastic, experimental surgery in healthy young women, the study’s cross-sectional design, the very premature data collection, the high complication rate and the large proportion of missing data, Olson-Kennedy and colleagues then make a completely unwarranted recommendation. Based on their study’s results, they say, “changes in clinical practice and in insurance plans’ requirements for youth with gender dysphoria who are seeking surgery seem essential. Youth should be referred for chest surgery based on their individual needs, rather than their age or time spent taking medication” [15].

I give this example to illustrate the fact that while rigorous systematic reviews look carefully at every detail of included studies, noting several types of epidemiologic bias, missing data, adverse events, conflicts of interest, spin, and things that just don’t make sense, the Cornell authors seem automatically to have believed the conclusions of every study reporting positive outcomes. Studies reporting negative outcomes, or no effect were not taken into account.

This is a potentially dangerous approach. Policy makers and clinicians often take systematic reviews quite seriously, but most lack the skills or the time to discern whether a systematic review is done well or poorly, nor to know whether a review’s overly favorable “findings” should be trusted. It is a similar situation with health guidelines.

CONCLUSIONS

Activist-driven transgender research methods are incompetent and reckless. Anonymous Cornell University authors did very poorly in conducting a systematic review. “Findings” of this document should be ignored. Similarly, UCSF’s transgender guidelines were developed using spurious, ad hoc methods. Both institutions should strongly consider removing these documents from their web sites to prevent potential patient harms that may accrue if individuals, clinicians and policy-makers were to take their “findings” and “recommendations” at face value.

REFERENCES

  1. Zucker KJ. Epidemiology of gender dysphoria and transgender identity. Sex Health. 2017 Oct;14(5):404-411.
  2. de Graaf NM, Carmichael P, Steensma TD, Zucker KJ. Evidence for a Change in the Sex Ratio of Children Referred for Gender Dysphoria: Data from the Gender Identity Development Service in London (2000-2017). J Sex Med. 2018 Oct;15(10):1381-1383.
  3. Kaltiala-Heino R, Bergman H, Työläjärvi M, Frisén L. Gender dysphoria in adolescence: current perspectives. Adolesc Health Med Ther. 2018 Mar 2;9:31-41.
  4. Zucker KJ. Adolescents with Gender Dysphoria: Reflections on Some Contemporary Clinical and Research Issues. Arch Sex Behav. 2019 Oct;48(7):1983-1992.
  5. Steensma TD, Cohen-Kettenis PT, Zucker KJ. Evidence for a Change in the Sex Ratio of Children Referred for Gender Dysphoria: Data from the Center of Expertise on Gender Dysphoria in Amsterdam (1988-2016). J Sex Marital Ther. 2018;44(7):713-715.
  6. Littman L. Parent reports of adolescents and young adults perceived to show signs of a rapid onset of gender dysphoria. PLoS One. 2018 Aug 16;13(8):e0202330.
  7. Chen D, Hidalgo MA, Leibowitz S, Leininger J, Simons L, Finlayson C, Garofalo R. Multidisciplinary Care for Gender-Diverse Youth: A Narrative Review and Unique Model of Gender-Affirming Care. Transgend Health. 2016 Jul 1;1(1):117-123.
  8. Rafferty J. Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents. Pediatrics. 2018 Oct;142(4).
  9. Spivey LA, Edwards-Leeper L. Future Directions in Affirmative Psychological Interventions with Transgender Children and Adolescents. J Clin Child Adolesc Psychol. 2019 Mar-Apr;48(2):343-356.
  10. Byne W, Bradley SJ, Coleman E, et al. Report of the American Psychiatric Association Task Force on Treatment of Gender Identity Disorder. Archives of Sexual Behavior. 2012;41:759-796.
  11. Olson-Kennedy J, Chan YM, Rosenthal S, Hidalgo MA, Chen D, Clark L, Ehrensaft D, Tishelman A, Garofalo R. Creating the Trans Youth Research Network: A Collaborative Research Endeavor. Transgend Health. 2019 Nov 1;4(1):304-312.
  12. Levine SB. Ethical Concerns About Emerging Treatment Paradigms for Gender Dysphoria. J Sex Marital Ther. 2018 Jan 2;44(1):29-44.
  13. Levine SB, Lothstein L. Transsexualism or the gender dysphoria syndromes. J Sex Marital Ther. 1981 Summer;7(2):85-113.
  14. University of California, San Francisco. Center of Excellence for Transgender Health. Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People. “Initiating hormone therapy.” Available: https://transcare.ucsf.edu/guidelines/initiating-hormone-therapy [accessed 26 February 2020]
  15. Olson-Kennedy J, Warus J, Okonta V, Belzer M, Clark LF. Chest Reconstruction and Chest Dysphoria in Transmasculine Minors and Young Adults: Comparisons of Nonsurgical and Postsurgical Cohorts. JAMA Pediatr. 2018 May 1;172(5):431-436.
  16. Turban JL, Beckwith N, Reisner SL, Keuroghlian AS. Association Between Recalled Exposure to Gender Identity Conversion Efforts and Psychological Distress and Suicide Attempts Among Transgender Adults. JAMA Psychiatry.
  17. D’Angelo R. Psychiatry’s ethical involvement in gender-affirming care. Australas Psychiatry. 2018 Oct;26(5):460-463.
  18. Horvath H. The Theatre of the Body: A detransitioned epidemiologist examines suicidality, affirmation, and transgender identity. 4thWaveNow, 19 December 2018. Available: https://4thwavenow.com/2018/12/19/the-theatre-of-the-body-a-detransitioned-epidemiologist-examines-suicidality-affirmation-and-transgender-identity/ [accessed 26 February 2020]
  19. Cornell University, Public Policy Research Portal. “What does the scholarly research say about the effect of gender transition on transgender well-being?” Available: https://whatweknow.inequality.cornell.edu/topics/lgbt-equality/what-does-the-scholarly-research-say-about-the-well-being-of-transgender-people/ [accessed 26 February 2020]
  20. Shea BJ, Reeves BC, Wells G, Thuku M, Hamel C, Moran J, et al. AMSTAR 2: a critical appraisal tool for systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both. BMJ. 2017 Sep 21;358:j4008
  21. Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009). Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Med 6(7): e1000097. doi:10.1371/journal.pmed1000097
  22. Ioannidis JP. Evidence-based medicine has been hijacked: a report to David Sackett. J Clin Epidemiol. 2016 May;73:82-6.
  23. World Professional Association for Transgender Health (WPATH). Standards of Care, version 7 (2011)
  24. University of California, San Francisco. Center of Excellence for Transgender Health. Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People. Available: https://transcare.ucsf.edu/guidelines [accessed 26 February 2020]
  25. University of California, San Francisco. Center of Excellence for Transgender Health. Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People. “Grading the evidence.” Available: https://transcare.ucsf.edu/guidelines/grading [accessed 26 February 2020]
  26. Balshem H, Helfand M, Schünemann HJ, Oxman AD, Kunz R, Brozek J, et al. GRADE guidelines: 3. Rating the quality of evidence. J Clin Epidemiol. 2011 Apr;64(4):401-6.
  27. Guyatt G, Oxman AD, Akl EA, Kunz R, Vist G, Brozek J, et al. GRADE guidelines: 1. Introduction-GRADE evidence profiles and summary of findings tables. J Clin Epidemiol. 2011 Apr;64(4):383-94.
  28. Andrews J, Guyatt G, Oxman AD, Alderson P, Dahm P, Falck-Ytter Y, et al. GRADE guidelines: 14. Going from evidence to recommendations: the significance and presentation of recommendations. J Clin Epidemiol. 2013 Jul;66(7):719-25.
  29. Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck-Ytter Y, Alonso-Coello P, Schünemann HJ; GRADE Working Group. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ. 2008 Apr 26;336(7650):924-6.
  30. Streed CG Jr, Harfouch O, Marvel F, Blumenthal RS, Martin SS, Mukherjee M. Cardiovascular Disease Among Transgender Adults Receiving Hormone Therapy: A Narrative Review. Ann Intern Med. 2017 Aug 15;167(4):256-267.
  31. Irwig MS. Cardiovascular health in transgender people. Rev Endocr Metab Disord. 2018 Sep;19(3):243-251.
  32. Alzahrani T, Nguyen T, Ryan A, Dwairy A, McCaffrey J, Yunus R, et al. Cardiovascular Disease Risk Factors and Myocardial Infarction in the Transgender Population. Circ Cardiovasc Qual Outcomes. 2019 Apr;12(4):e005597.
  33. Zucker KJ, Lawrence AA, Kreukels BP. Gender Dysphoria in Adults. Annu Rev Clin Psychol. 2016;12:217-47

AFFIRMATIVE QUACKERY: Harry Benjamin and WPATH

Q: Why does the “World Professional Organization for Transgender Health” (WPATH) insist that if kids or adults claim to be “trans,” they REALLY ARE “trans,” and that psychotherapy is pointless?

A: It’s because WPATH slavishly follows the stupid whimsies of super-quack HARRY BENJAMIN, their great inspiration and patron saint. This thread will explain.

[Please click the images to enlarge them.]

Harry Benjamin was born in Germany in 1884. He received his medical degree in 1912. He promptly hitched his wagon as assistant to a quack called Friedmann who was going to the USA in 1913 with an implausible tuberculosis “cure” — using turtle fluids. Naturally, a scandal ensued.

Benjamin then became devoted to the crackpot ideas of Austrian quack Eugen Steinach. The first was that vasectomies would restore vim & vigor to middle-aged men. This is false. Steinach’s true delight of quackery was “sex change” operations on guinea pigs. Benjamin LOVED this.

Anyway, in the late ’20s, Steinach introduced Benjamin to Freud. It did not go well. This is the main reason why sensible psychotherapeutic approaches are being called “conversion therapy” by “trans” industry flunkies like Johanna Olson-Kennedy, Diane Ehrensaft, Jack Turban and the other WPATH “affirmative care” cultists.

More about Benjamin’s irrational attitudes toward psychotherapy, by his friend and biographer Dr. Ethel Person. Important to read.

And then? Benjamin glommed onto the famous “Christine Jorgenson” case and became his personal doctor. People started to listen to this super-quack, an utter fool. WPATH was formerly named for Harry Benjamin, changing its name in 2007.

These items are well worth a close read.

This seems perfectly legit.

WPATH and AFFIRMATIVE QUACKERY derive straight from this con-man.

After tricking desperate folks with a fake TB cure made from turtle fluids (1913), WPATH patron saint Harry Benjamin got rich doing vasectomies on the 1920s version of yuppies.

More Harry Benjamin fraudulent pseudo-science. Remember, all he is doing is vasectomies on these men.

The article notes that Benjamin’s mentor Steinach is now experimenting on women. Within the next year or so, Benjamin added X-Raying of women’s ovaries to his quackery.

WPATH “still reveres its links” to psycho-quack Harry Benjamin.

Harry Benjamin’s Wikipedia page is grossly deficient. It’s a white-wash, omitting all of his quackery except the “trans” quackery. It grossly minimizes his quackery with the “turtle vaccine,” and doesn’t even mention his Steinach quackery. If you know how to fix up Wikipedia, this would be useful to do.

And yet, how blatant:

“Believe the child” — Precisely the mantra of WPATH and its “affirmative care” model — which is pure AFFIRMATIVE QUACKERY.

There is no such thing as “trans”

There’s no such thing as “trans.” You’ve been lied to. Everyone is free to dress as they please, use any mannerisms and voices they please. However, it’s not possible to change from one sex to the other. “Gender” is the same as it always has been: Stereotypes of appearance, mannerisms and roles prescribed by society for each sex, respectively.

Good for you if you’re a man who feels most comfortable wearing a dress, painting your face, having perfect nails, whatever may be the variations on stereotypic “femininity” that make you feel better. It’s great that as a man you want to smash the whole “gender” system, or at least short-circuit it like David Bowie and Boy George used to do. Wear what you like; don’t give a shit what people say; and get people thinking.

But do you see what the problem is? You insist that you’re not a man at all, but some sort of “woman.” How depressing — how obviously incorrect — how boring. By maintaining this position — which no-one actually believes; probably not even you — there is a sense of waste. It’s like you perhaps aren’t smart enough to pick up the very basic piece of information: you’re male. Or maybe you’re just too crazy. No-one knows, but the whole charade quickly becomes tedious for everyone except you.

Because you’re not a woman at all. Having sexy feelings about women’s garments doesn’t mean you’re a woman. Yearning! Pining! Keening! “to be a woman” doesn’t mean you’re a woman. And taking hormone drugs, having drastic surgeries — all for nothing. You will just never be a woman. You’re going to need to understand that message very well.

And before you start to say that it doesn’t hurt anyone, you only want to pee, it’s just social fluff, you’re nice “ladies,” come on, please? live and let live OK? — It doesn’t work that way. It wasn’t as bad 30 or 40 years ago when cocks-in-frocks were extremely rare. Women often tolerated their presence in women’s protected spaces. Nowadays, however, someone has left open the barn door, and all the male farm animals are in rutting mode, running amok. Crazy, horrible things are happening. In part due to your activism and agitation about all things “trans,” thousands of women and men foolishly believe they’re really the opposite sex; and so do thousands of children.

These kids are given “puberty blockers” and then cross-sex hormones, which they will need to take for life. Girls age 13 are getting their breasts chopped off in CaliforniaBoys age 16 are getting their genitals mutilated until they superficially resemble those of women; but they are a crude facsimile, little more than a fuck-hole. The girls have the healthy organs of their reproductive systems — ovaries, uterus, fallopian tubes — hacked out around that time too. This is no joke or exaggeration: it’s happening. This depravity with the children will be shut down.

Men’s lives and women’s lives are radically different from one another, starting from the youngest days. Yet you insist your feelings and experiences are those of a woman.

Sure, some drunken fool at 3 am in the backstreets might “cat-call” you as you confidently & fearlessly stride past him (this secretly turns you on); or maybe your male boss recently stole one of your ideas and didn’t mention that it was yours. Many men who exhibit “trans” behavior claim that with such experiences, they “really understand the plight of women.”

To call this a disgusting insult to women doesn’t even begin to scratch the surface.

Your extreme cosplay also puts women and girls in danger. Men keep the same rate of violent crime as other men, even after they’ve had their genitals mutilated. Women in changing rooms, restrooms and other protected spaces cannot just assume you’re a “nice lady” — In Sweden, the male-pretending-to-be-female violent crime rate was 18x that of women.

Bizarrely, you cats demand that the word “woman” and “female” be replaced in all health messaging concerned with pregnancy and childbirth, pap smears, uterus, ovaries, etc. — Replaced e.g. by “pregnant people” — Even though only women, indeed only females of any mammalian species, have ever been pregnant in the past 200 million years.

Why? You feel “dysphoric” with rage that you are still not women, and never will be. And just as you want to replace those words, your real endgame is to exterminate and replace women with your own fake selves. After all, you’ve suffered so much being “misgendered” all your life — you’re so much more deserving of femininity’s wonders than mere “ciswomen.” The “trans” industry will continue to cock up functionless simulacra of women’s “body parts” for you to install, if you’ve got the loot — oh wait, I forgot: You’ll have it covered in your health plan. They may even take wombs from the bodies of the many confused young women who think they can change into “men.” And someday, crooked doctors will grow a fetus in a test-tube somewhere and stick it in your abdomen for a couple of minutes. The intense pleasures of your countless hours spent watching “feminizing” self-hypnosis and rumination videos will now seem old-fashioned. What debauchery.

As clinicians routinely observed for decades, until it became “transphobic” to do so, you guys have mental health problems. No shame in that — but you should get the right treatment. Transtreatment, based on fantasy, wishful thinking and misogyny, only makes you worse.

I’ve read all your “science.” It’s grossly over-interpreted and “spun.” The studies are completely rotten with selection bias, confirmation bias, attrition bias, conflicts of interest and other serious problems. You male transters also seem to die at much younger ages, even when overall mortality is similar to that of other men. Indeed there is zero credible evidence for benefit in the fake “transition,” for anyone. You’re part of a big, stupid societal experiment, just lab rats, and you love it. The whole enterprise is a fraud.

And despite your own massive, incalculable transgression in women’s lives, you were deeply enraged enough to write your Medium article: Another man has mimicked women in film — but his feelings are the wrong feelings. In your narcissism, you completely miss the irony of this.

Give it a rest. Don’t you see how comical you’ve become? Tragically comical. You’re in a cult. It’s time for you and all these other masqueraders to have a good think about emerging from the fake “trans” miasma. You can do it. I did it (I was 13 years 100% in the mix and “happy,” until one day I saw through the lies, and wasn’t). So you’d best get a move on.

Ten things you’re not supposed to know about the transgender industry

olson-1HEALTHY 13 YEAR OLD GIRLS GO UNDER THE KNIFE. At Children’s Hospital Los Angeles, transgender industry Dr. Johanna Olson-Kennedy refers healthy but confused teen girls as young as age 13 to the surgeon for radical mastectomy — “top surgery,” or “chest surgery.” Girls and young women will likely also have their uterus, ovaries and fallopian tubes rooted out before too long. Many even go through outrageous surgical horrors to jerry-rig some sort of pseudo-“penis.” Because they’re “men”! Or at least, so they have been led to believe by the “trans” industry.

And what about the “women”? In the United States, boys who think they’re really girls can get their genitals de-fleshed and inverted to become a pseudo-“vagina” when they are as young as age 16. Surgeons say they would prefer to do these operations before the boys finish high school, because they suppose the parents would wait on these lads — oh sorry — “girls” — hand and foot during the several months of aftercare

Forget about waiting for years and years to get this party started, going to therapy or any of that nonsense. Many “gender” clinics in the USA go by the “informed consent” model — which means it’s really “on demand.” Health insurers now scramble to cover the greatest variety of unnecessary surgical procedures for teens and adults with the minor mental illness of “gender dysphoria.”

EPIDEMIC. The backdrop to this mayhem is that in North America, Britain, Europe, Australia and New Zealand, there is currently an epidemic of rapid-onset gender dysphoria (ROGD) in adolescents and young adults. It is called “rapid onset” but it could just as well be called “sudden onset.”Young people, primarily young women, are suddenly declaring themselves “trans” and demanding to “transition,” despite never previously having shown any confusion about their sex. Whole friend groups at school are “coming out as trans.” It is a social contagion, developed as young people ruminate (often with a friend) about how dissatisfied they are with their lives, and idealize their fabulous futures as members of the opposite sex. School adminstration lackeys of trans activist organizations have given them unparalleled access to kids in schools, and they have taken full advantage of it. The situation in the United Kingdom is much the same.


But transgender industry personnel utterly deny the existence of ROGD, despite abundant evidence for it. Why do they deny it? Because they are desperate for an innate, inborn, “opposite sex gender identity” to be a thing, nonsensical as that sounds. It gives the male transgenderists an “alibi”against the embarrassing truth, or so they hope.PREDICTABLE. Meanwhile, even younger children continue to be “transed” at a nauseatingly high rate. Why? A fringe group of ideologue doctors promoting “affirmative care” has gained some influence these days. Their main mantra is to “listen to the child” — and make enormous life-changing decisions for that child, based on childish prattle. For example, if little Johnny seems to like sugar & spice & everything nice, that means he is a girl. If little Jenny seems to like snips & snails & puppy-dog tails, that means she is a boy. Hey, Johnny says “she” wants to “socially transition”! How fun!

Well, except that a study showed that children (especially boys) who “socially transitioned” were much more likely to “persist” into a drug-blocked puberty (which generally includes, at no extra charge, sterilization). Puberty-blocking drugs — an implant in the arm — are typically prescribed from around age 8 or 9. From around age 13, doctors hook the kids up with the hard stuff — a lifelong regimen of synthetic estrogen for the boys, synthetic testosterone for the girls. And soon: A horrific range of unnecessary surgeries.


WRONG TREE. Despite decades of “research” in which transgender industry scientists have tried to locate the source of “opposite sex gender identity” somewhere in the human body, the best evidence they can put together is wildly speculative at best, with huge gaps. Copious “spin” is used to cover over these gaps. Where they say “not completely understood,” you can take that to mean they have no idea. That’s because this “gender identity” doesn’t exist. It’s all just mind games, word-play and auto-suggestion. Transgender activists and their admiring “allies” in academia are desperate to prove that it does exist, because the alternative explanation — that perhaps they really do have mental illness —likely a personality disorder — is hard to bear. However, there should be no stigma or shame in mental illness. It is best to be honest with oneself.

ACCURATE. Until recently, “gender dysphoria” more commonly was called “gender identity disorder.” Most people understood this to mean something like “GENDER IDENTITY… (disorder).” It really should convey something more like this: “gender… IDENTITY DISORDER.” Because it is a disorder of identity, perhaps part of a personality disorder.

HYPEPeople who believe themselves to be “trans” are *not* at an extraordinarily high risk of suicide. That’s just the propaganda used to socially engineer society to give them what they want. Suicide attempt rates are higher than those in the general population, it is true, but they are similar to rates in other relevant sub-populations, such as people with mental illness and people who have been bullied. The extremely high rates of 40% or more that have been reported in the mass media were derived from surveys using faulty methods. It is surprising that well-funded transgender activist organizations would take such short-cuts and then report findings with a straight face, but that’s what they’ve done.
MANIPULATION. Nor are they at particularly high risk of being murdered. Middle-class male transgenderists in high income countries often sound the alarm, poor them, they are being murdered in droves. Except they’re not. A 2017 study that used data from the “Transgender Day of Remembrance” organization found that men who were considered to be “trans” became homicide victims in the United States at a similar or even lower rate to persons in the general population. A subsequent informal analysis compared country-specific “trans” homicide rates from the “Transgender Europe” organization to general population homicide rates from the United Nations Office on Drugs and Crime. Again, notwithstanding high numbers of homicides in some countries, the rates were similar around the world — the “trans” rate is comparable to that of the general population. If thousands of ordinary folks are being murdered in a given country, a proportional number of “trans” are murdered.

STRAIGHT. In high-income English-speaking countries, the vast majority of male transgenderists — as much as 90% of such men — are heterosexuals. They are straight transvestites, just as we’ve had in society for hundreds of years. In the past few decades, especially since the internet came along, large numbers of these men begin an illusory “transition,” in the belief that they can magically become “women” through taking synthetic estrogen. They typically have autogynephilia, defined as an erotic attraction to a fantasy image of themselves “as women.” Most of them claim to be “lesbians,” which is an impossibility because they are men. Indeed, a large proportion of these guys in recent years don’t bother having genital surgery. Instead, they speak of their “female penis” (sic)Even so, they aggressively pursue lesbians. When women reject them, they condemn the women as “bigots.” If they go on dates with other men, researchers suggest it is

DANGEROUS. It is not true that men claiming to be “women” are perfectly safe “nice ladies” in the presence of real women in sex-specific restrooms, locker rooms etc. There are numerous examples of male trans violence, voyeurism and other crimes in these and other settings. Indeed, there is evidence from a study in Sweden that even after their genitals had been surgically rearranged, men who claimed to be women had a similar conviction rate for violent crime as age-matched control group men. This rate was 18 times that of age-matched control group women. In other words, they “kept a male pattern of violent crime.” Unfortunately, much crime committed by male transgenderists nowadays is officially recorded as crime by “women.” Our crime data are being skewed terribly by politically-correct fear of “misgendering” these guys. Meanwhile, on the internet as well as in real life, they quite openly make violent threats to women.

REGRET. Although transgender industry activists and researchers claim that the rate of regret in “trans” people after surgery is extremely low, it is likely instead to be quite high. When regret is even assessed in follow-up studies, it is often defined in very narrow terms, e.g. there must be a notation about this in the patient’s medical record. Meanwhile, losses to follow-up are often quite high, well above the 20% levels that in other research would be an enormous red flag of trouble. After all, these patients need to take hormone drugs for the rest of their lives. How could 30%, 40%, 50% just be “lost,” in our high-tech world? They must be in care somewhere, right? Have they killed themselves? Possibly. Although suicide rates are not as stratospheric as trans propaganda would suggest, they are still at higher risk than the general population.

These are just a few of transgenderism’s “inconvenient truths.”

Yet another wave of narcissistic rage sweeps through Transworld

It is striking to see history repeat itself yet again, as a new batch of elite male transgenderists and their admirers lash out angrily to rebuke heresy and punish heretics. The heresy to which I refer is that which stands obstinate in its opposition to transgender ideology’s “born this way” dogma, and rejects its ludicrous, flaky lucubrations. Among the masses of mincing men who insist against overwhelming evidence that they are actually “women,” any scientific evidence that remotely hints at a psychosocial etiology for “gender dysphoria” must be killed immediately with fire and its bearer exterminated. This is the cultish sacrament of male transgenderists: the ancient transcycle of narcissistic rage.

This time around, it is rapid onset gender dysphoria (ROGD) that must face TransWorld’s florid, torrid flames. A mob of petty tyrant transpals in petticoats gangs up to stifle academic freedom and tries to destroy the career of a highly regarded scientist, Dr. Lisa Littman of Brown University.

Given the irreversible nature of all current transgender intervention — drastic surgeries to remove healthy organs (breasts, uterus, ovaries, fallopian tubes in women; testicles in men); not to mention other serious surgeries to create a pseudo-“penis” or pseudo-“vagina”); lifelong regimens of drugs that carry significant risk of cardiovascular events; and never mind that there has never been even one comparative study of cognitive-behavioral therapy or other highly applicable therapies to alleviate gender dysphoria without all the surgical & hormonal rigamarole — one might suppose that transgender activists would support Dr. Littman’s research.

One would be wrong. Instead, they are doing their best to suppress it. Wouldn’t it be better to weed out young people who didn’t quite realize what they were getting into when they ruminated themselves into the trans industry’s grotesque corridors?

It is an especially dangerous time for girls and young women who get the notion in their heads that they’re “trans.” Activist physician Dr. Johanna Olson-Kennedy of Children’s Hospital Los Angeles has referred at least two 13 year old girls for radical mastectomies of their healthy breasts, and many other girls aged 14, 15, 16. Olson-Kennedy actually promotes the idea that such girls should have this massive surgery as quickly as possible after their self-diagnoses, even before taking testosterone.

But this extreme risk of iatrogenic harm does not dismay today’s dress-up boys, not at all. Despite “trans” industry research having chased its tail and gone nowhere for decades, it is crucial to their egos that the world believe it’s “settled science,” people are “born trans.” Any intimation to the contrary triggers trans-tantrums.

Nearly 15 years ago, a different group of men who shared a common interest in intense mimicry of “feminine” stereotypes flipped their wigs and exploded in narcissistic rage when Dr. J. Michael Bailey of Northwestern University published “The Man Who Would Be Queen.” This book describes autogynephilia, an “erotic target location error” and an important motivating force in most male transgenderism. Autogynephilia is a paraphilia in which men fixate on fantasies of themselves “as women,” dressing themselves up in “feminine” habiliments and conducting predictable ancillary activities. It is a key characteristic of male transvestism. A large proportion of men who insist they are actually “women” were ordinary transvestites before they lost their grip on the frayed ends of sanity, and “transitioned.

Naturally, the men who were outraged that Bailey had let the cat out of the bag in a book written for lay audiences considered it right to send psychotic, obscene letters to his family and try to get him fired from his job. They did not succeed in the latter goal, but they certainly brought plenty of distress and discomfort to his family.

All these years later, the anti-autogynephilia propaganda of these activists has become a kind of translore, bedtime stories for the latest lads in lingerie. And they do not rage only against Bailey — no indeed. Equally shrill, even more deranged ranting is reserved for Dr. Ray Blanchard, who first conceptualized and described the varied dimensions of autogynephilia in his work with hundreds of patients at the Centre for Addiction and Mental Health (CAMH) in Toronto during the 1980s and 1990s. And of course, for the high transcrime of suggesting that a sensible process of becoming more comfortable in one’s own body was preferable to an immediate transing of small children, menacing masqueraders actually did pressure CAMH bureaucrats to fire Dr. Ken Zucker, even after the transprop was shown to be false. (Dr. Zucker has since been vindicated, with an apology and a financial settlement from CAMH.) The lies they routinely propagate about all these men, as “received ideas” among transgenderists, are wildly untrue, and in many instances are libelous.

And now these frocked fools are pulling out the stops in attacking Dr. Littman, trying their hardest to humiliate her, destroy her credibility, destroy her career. They felt so threatened by the findings of this one little study that they mobilized their online mobs to disparage it and shove it down the memory hole. In reality, however, they brought this paper much more attention than it might otherwise have had, and likely helped raise the awareness of many. (As of 25 January 2019, the article has been read more than 129,000 times, not counting PDF files sent by e-mail or linked from other web sites.)

Lots of books and papers

=== BOOKS: ===

ENDOCRINOLOGY:

EPIGENETICS:

Excellent book by E. Keverne of Cambridge:
Beyond Sex Differences: Genes, Brains and Matrilineal Evolution (2017):

PSYCHOLOGY (transdiagnostic approaches):

OTHER PSYCH BOOKS:

=== PAPERS: ===

“TRANSDIAGNOSTIC” approaches:

OTHER PAPERS about TRANSGENDERISM

Long-term follow-up

Attachment/separation/trauma

Cognitive behavioral therapy

Old paper by Pfafflin & Junge (1992)

This was a small book, written in German and published in 1992. It was re-published in the International Journal of Trangenderism in 1997. In the old days, this journal often published things that the trans industry now would consider inconvenient. The current journal does not link to these archives.

This excerpt is interesting because it supports what we’ve been saying about suicide attempts being in the 20%-ish range (even during such “transphobic” times), not the uniquely alarming “41%” of the transpropaganda.

To determine the pre-surgical suicidal tendency the use of a bigger sample description independent of follow-up literature is useful. Among 479 MTF and 285 FTM who were examined in the Gender Dysphoria Program in Palo Alto, California (USA), 25.5% of the MTF and 19% of the FTM immediately before or a longer time before the treatment started had attempted suicide (Dixen et al., 1984). In the same dimensions are the figures from The Netherlands. According to them, of 168 MTF, 19.3% had attempted suicide before treatment start and of 55 MTF, 18.6% had tried it prior to treatment (Verschoor & Poortinga, 1988). In 18 of the follow-up studies referred to here are indications about the pre-operative suicidal tendencies. In a major number of publications, it is around 20% or even higher (e.g., Hoenig et al., 1971; Wålinder & Thuwe, 1975; Wyler, 1978; Sörensen, 1981 a, b; Kuiper & Cohen-Kettenis, 1988; Dudle, 1989; Wiesbeck & Täschner, 1989; Stein et al., 1990). Throughout all, one can find the difference between the relatively high suicidal tendency of the MTF and the relatively low one of the FTM.

Friedemann Pfäfflin, Astrid Junge, Sex Reassignment. Thirty Years of International Follow-up Studies After Sex Reassignment Surgery: A Comprehensive Review, 1961-1991 (Translated from German into English by Roberta B. Jacobson and Alf B. Meier)