I’m going to say something that a lot of people who have been supportive of me are not going to like to hear, but here we go, be strong folks:

Adults should be able to medically transition without being forced to explore co-morbid diagnoses that might be contributing to their gender dysphoria.

Now wait.

Here’s the next piece to that: every adult, to have true choice, needs to be provided with the opportunity to get assessed for the various conditions that contain, as part of their profile, identity disturbances, obsessive thinking, and dissociation. .

Now here’s the next piece: it’s not a true choice if getting assessed is more expensive than an appointment to get hormones at an informed consent clinic. It’s not a true choice if the appointments to get assessed are farther away and the waiting list is longer than getting hormones. I think you should have the right, if you’re visiting an informed consent clinic, to opt to see a psychologist in a timely, convenient, and non-cost-prohibitive manner.

Now, I think the stigma to mental health conditions that include identity disturbances is a big enough deal that it’s still not a fair fight. There are big consequences that people have to weather when they get stigmatized diagnoses. So I think many adults who in a scenario where they could benefit from assessment, and it’s not any more expensive or harder than getting on hormones, and who could find different ways to cope with their symptoms, would still choose medical transition.

And you know what? I think it’s good for them to have the right to do that.

Because adults have final say over their bodies. Adults have the right to take risks with their bodies. I wish, for everyone who experiences gender dysphoria, that everyone would be risk-averse in this process, and give themselves the opportunity to face some truths about their mental health that could be incredibly hard to face, but just because that’s my wish does not mean my wish should infringe on another adult’s rights.

Here’s what I think gets misunderstood about assessment: rich people with mental illness have a lot more access to it than poor people. Assessments cost money to use and money to pay people to interpret. When I got my letter for hormones, I believe I took the GAD-7 and I was probably verbally assessed for a variety of mental health symptoms. I didn’t take a battery of tests. I have a gig right now where part of my duties are to score and interpret initial assessments, and the whole battery takes about an hour and half for the patients to complete. I never did anything like that when I was transitioning. But by that point in my life I’d always been to poor people therapy- trainees and sliding scale operations.

The one time I have gotten to take a full battery like that it was at Kaiser, when I was first detransitioning, and I was having intense panic attacks. But yeah, I got to my surgical consult without ever having that opportunity, no one said, “Yo I could make a referral to a psychologist for you, if that would be helpful.”

So I think everyone who experiences gender dysphoria deserves to get to take those assessments. Do I think they should have to? No. I think the option should be there- available, convenient, not expensive. Just so people have the chance, and if they feel like they know what they want to do, well it’s your body and your life.

I believe in the adult right to medical transition because I believe autonomy is a principle that should be defended.

Which is also why I think minors are a different deal. Yes, developmentally our trajectory is individual- some 17 year olds are exceptionally mature, some 25 year olds have the decision-making abilities of 8 year olds. But in America we’ve landed on the age of 18 as the age when you get to take serious risks with your body, and I think medical transition should be one of those risks.

You’ll notice I’m not talking about brain sex. I just don’t think anyone understands how gender identity and brain development interact, besides the evidence that exogenous hormones have an impact on the density of connections in parts of the brain. But just on a fundamental level, the procedures you feel you need in this world are your decision. Do I wish the social hierarchies young queer people tended to form were a lot less cavalier about these choices and also a lot less authoritarian in their ideology? Yeah, absolutely. But if you asked me to judge whether any given individual should pursue medical transition, I wouldn’t give you an answer. Because they are the person who will live out the effects of their choices, and thus they have the right to make those choices.

People have asked whether I would ever work, as a therapist, with someone considering medical transition. No, I wouldn’t take the ethical risk. If someone specifically said, “Hey I’d like to work with you to see if there’s some other ways I could manage my gender dysphoria, but I’m just giving this a fair shot and then I’m making my own decision” I might participate in that. Like, a decade down the road when I have a lot more experience treating dissociation and identity disturbance. I wouldn’t ever put myself in the position of having authority over whether someone got to make those choices. I’d never put myself in the position of being the clinician who writes the letter to an endo or a surgeon.

Parents have written me a lot asking what my parents did to get me to detransition. My parents didn’t do a thing. I was 30, I was totally independent, my choices were my own, and honestly we barely talked about it. I think that autonomy helped me, eventually, choose to make self-loving choices. Because I wasn’t struggling against family for control of my life, so they didn’t turn into the bad guys, and eventually it just became clear I wasn’t getting what I expected to out of medical or social transition. Honestly, the people who did the most that led to my detransition were my coworkers at the informed consent clinic I worked at, just in terms of when they would be ok to me (rarely, and only when I started presenting femme which was so backwards and sick and humans are the worst), and I still struggle with feeling angry at them for that. So I think the less other people attempt to control a person’s process the quicker a person can take responsibility for where they’re headed.

I do think having the safety net of a family I could kind of collapse on when I detransitioned was key to the process. They never said anything like, “we told you so” either. So if you’re trying to follow my parents’ example you’re going to have to become very chill. (And they are not generally chill people, so I think it was a real effort for them.)

Anyways. I think it’s super valuable for detransitioners to tell their stories and for people to talk about the downsides to medical transition- ESPECIALLY what we don’t know about how testosterone affects our organs. We absolutely need to be demanding real research on blockers and testosterone. (I think they got the risk management with estrogen mostly down in the nineties.) I just think when it comes down to medical ethics, we also have to defend people’s autonomy. Autonomy and Non-maleficence- you gotta do both, you can’t just pick one.

Oh one more thing- do I think the doctors prescribing hormones should be doing at least verbal assessments for things like hallucinations,delusions, paranoia, and personality splitting? Yes. Those symptoms compromise a person’s autonomy- you wouldn’t feel good selling an actively delusional person a boat, you want to make sure you’re not handing them hormones either. You catch wind of those symptoms, you can explain to the patient why you need them to get a full assessment with a psychologist. Medical ethics gets pretty specific to the situation quickly, and honestly any time it isn’t getting specific quickly you’re probably being unethical.

Ok, sorry to disappoint with my moderate stance, yet again. But it is important. Autonomy is foundational to people’s growth, and we gotta make sure that when we’re speaking up and making criticisms we’re also keeping a focus on people’s autonomy.

The shit REMAINS COMPLEX. WHAT WHAT. NUANCE MOFOS.

One thought on “Autonomy

  1. Thank You Carey (this is Penny White not “real feminist history” I’m too lazy to change my wp name) Whether there are comorbid disorders or not, Sex Dysphoria is clearly very real & very painful. I have known people who found tremendous relief when they transitioned. I refuse to deny this reality. And these very same people – most of whom transitioned after having children & careers – have said that transition should only be a last resort due to how disruptive it is physically & socially. We should all be able to support this clearly effective form of palliative care without being accused of giving in to the “trans cult” just as we should be able to express fear & caution about child (and even young adult) transition without being called evil terfs & transphobes. Thank You for your kindness & sanity.

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