The Battle Over Gender Therapy

And just like that, after four years of painstaking work, Leibowitz, de Vries and the rest of their group were being called out as traitors by peers and the community they sought to care for. “We understood the enormity of the need for these standards from the beginning,” Leibowitz told me. “I’m not sure we recognized the enormity of the controversy. It’s a result of the fact that our world, the world of gender care, has exploded.”In the 1950s and ’60s, a small cadre of doctors in Europe and the United States started to talk about how to evaluate adults who wanted to medically transition. Harry Benjamin, the endocrinologist for whom WPATH was originally named, embraced the idea that the people he agreed to treat (mostly trans women) were “born in the wrong body.” Fearing lawsuits from dissatisfied patients, the doctors were quick to exclude patients for reasons of mental stability. And, arbitrarily, they only included those who they believed would go on to pass as the gender they identified with, as Beans Velocci, a historian at the University of Pennsylvania, wrote in an article last year in TSQ: Transgender Studies Quarterly. Some doctors made trans adults promise to live as heterosexuals after they transitioned.The small group of clinicians who wrote the first Standards of Care were all cisgender. After WPATH was created in 1979, transgender advocates increasingly gained influence in the organization, but many transgender people viewed subsequent versions of the standards as imposing paternalistic and demeaning barriers to treatment. For some genital surgery, the standards required adults to live for a year as the gender they identified with and to provide referrals from two mental-health professionals. The SOC8 is the first version to dispense with these requirements, adopting a model of “shared decision-making” between adult patient and surgeon.The leap toward medical transition for young people occurred in the Netherlands in the 1980s. Peggy Cohen-Kettenis, a Dutch clinical psychologist specializing in children, began receiving referrals of teenagers who were experiencing gender dysphoria (then called gender identity disorder). But therapy wasn’t the primary answer, Cohen-Kettenis, who is retired, told me over the phone this spring. “We can sit and talk forever, but they really needed medical treatment.” As their bodies developed in ways they didn’t want, “they only did worse because of that.” She decided to help a few of her patients start hormone treatments at 16 rather than waiting until 18, the practice in the Netherlands and elsewhere at the time. She monitored them weekly, then monthly. “To my surprise, the first couple were doing much better than when they first came,” she said. “That encouraged me to continue.”Cohen-Kettenis helped establish a treatment protocol that proved revolutionary. Patient Zero, known as F.G., was referred around 1987 to Henriette A. Delemarre-van de Waal, a pediatric endocrinologist who went on to found the gender clinic in Amsterdam with Cohen-Kettenis. At 13, F.G. was in despair about going through female puberty, and Delemarre-van de Waal put him on puberty suppressants, with Cohen-Kettenis later monitoring him. The medication would pause development of secondary sex characteristics, sparing F.G. the experience of feeling that his body was betraying him, buying time and making it easier for him to go through male puberty later, if he then decided to take testosterone. Transgender adults, whom Cohen-Kettenis also treated, sometimes said they wished they could have transitioned earlier in life, when they might have attained the masculine or feminine ideal they envisioned. “Of course, I wanted that,” F.G. said of puberty suppressants, in an interview in “The Dutch Approach,” a 2020 book about the Amsterdam clinic by the historian Alex Bakker. “Later I realized that I had been the first, the guinea pig. But I didn’t care.”Over the next decade, Cohen-Kettenis and Delemarre-van de Waal designed an assessment for young people who seemed like candidates for medical treatment. In questionnaires and sessions with families, Cohen-Kettenis explored the reasons for a young person’s gender dysphoria, considering whether it might be better addressed by therapy or medication or both. The policy was to delay treatment for those with issues like attention-deficit and eating disorders or who lacked stable, supportive families, in order to eliminate factors that might interfere with the treatment. “We did a lot of other work before letting them start, which created a lot of frustration for them,” Cohen-Kettenis said. “Maybe we were too selective in the early stages.” In retrospect, she says, she thinks young people who might have benefited were excluded.