A Response to 'Gender-affirming care model'

Dear 'practicing mental health professional'1,

Thank you for reaching out to me about your concerns regarding the gender-affirming care model. I appreciate the opportunity to discuss this important topic with a fellow mental health provider. That said, your letter left me quite perplexed. As a fellow mental health provider, I expected a more informed and compassionate perspective as opposed to the quagmire of misconceptions, offensive analogies, and what I can only call an 'ideology' that I found myself wading through.

First, let's address the analogy you used comparing affirming transgender identity to affirming someone who claims to "identify as having Down Syndrome". This comparison is as inaccurate as it is offensive. As you know, Down Syndrome is a genetic condition caused by the presence of an extra chromosome 21, while being transgender is a matter of gender identity, which is a person's deep-seated, innate sense of being male, female, or another gender 2. One does not "identify as having Down Syndrome," and before you go down that road, let me stop you right there. You are trying to equate a delusional claim to gender identity, and that is like comparing apples to oranges. This is called a false-equivelance and it is an invalid comparison to make, and as such, your entire argument that rests on this premise is invalid. I'm not sure how you managed to conflate the two, but I suggest you revisit the definition of gender identity in the APA guidelines3.

As for your cherry-picked references to the Cass Review4 and WPATH Files5, I can't help but wonder if you've actually read them in their entirety or just skimmed the sensationalized headlines. Yes, they highlight areas where more research is needed, but they don't negate the mountain of evidence supporting gender-affirming care. Furthermore, you seem to ignore the fact that not only are there serious methodological flaws in the Cass review identified already, as well as questions to it impartiality6, the 'WPATH files' report has been largely debunked, and has proven to be much ado about nothing7. It is like focusing on a single tree while ignoring the vast forest around it.

Speaking of evidence, have you taken a look at the numerous studies showing the significant benefits of gender-affirming care in reducing depression, anxiety, and suicidality among transgender individuals? 89 Or the fact that major medical organizations, like the AMA10 and APA11 , endorse this approach? I'm starting to think you might have missed a few crucial memos and studies, and someone has not been keeping up on your journal reading, I see?

Now, let's address the elephant in the room: your concern about enabling a delusion. I hate to break it to you, but the DSM-5 called, and it wants you to know that gender identity has been excluded from the criteria for delusion since 2013 12. It's not a belief or a choice, but an innate part of who someone is. We have known this for quite some time, but you know how the DSM folks are. It takes forever to finally approve a revision. Look how long it took them to stop saying that being gay is a mental disorder?13 Anyhow, I'm not sure how that memo got lost in translation for you, but I'm happy to send you a copy.

And don't even get me started on your "lack of long-term data" argument. By that logic, we should have withheld life-saving ART treatment from people with HIV/AIDS in the mid-1990s. Can you imagine the outcry or what the already terrible death toll was, or would be? The fact is, we have to make decisions based on the best available evidence, and right now, that evidence overwhelmingly supports gender-affirming care14 151617. And guess what? We even have some long-term studies that further reinforce its effectiveness18 .

As mental health professionals, our primary goal should be to alleviate distress and promote well-being based on the best available evidence. Withholding care that is known to be effective, even if long-term data is still being gathered, is not a neutral stance, but one that actively perpetuates harm against a vulnerable population. This is as unethical as it is shortsighted.

You mentioned detransition as a reason to question the gender-affirming model. While detransition does occur, it is rare, and the reasons behind it are often complex, including societal pressure, discrimination, and lack of support19 . If you factor out external influences on the reason for detransitioning, roughly .5% (+-) of all trans people detransition because they ultimately realized that they were not really trans. Half of a percent, give or take20 . The existence of detransitioners does not negate the validity or importance of gender-affirming care for the vast majority of transgender individuals. We do not throw out the baby with the bath water, otherwise we would never offer chemo again.

If you truly wish the best for those dealing with gender-related distress as you claim, then I suggest you start by educating yourself on the current research and best practices. Because as far as I can tell, your powerful statement of care is contradictory to the science and facts surround trans folks and their care. Your belief that sex and gender are not two discreet categories is a belief you choose to have contrary to the science, data, and facts 21.

At the risk of being rather direct, I urge you to take a step back and re-evaluate your stance. As mental health professionals, our job is to provide compassionate, evidence-based care to all of our clients, not to perpetuate harmful misconceptions. The facts, data, and science do not care about your ideological beliefs on sex and gender. But the duty of care you have to provide the best evidence-based care for the for your patients absolutely does depends upon your ability to follow the data and science, and to recognize the difference between a peer-reviewed article in nature vs. pseudoscientific articles and discredited and falsified studies. To accept that new evidence can and should change our beliefs and perspectives, lest we fall into the trap of ideologues and echo chambers. If we had not, we would still be using leeches and trepanning to treat chronic hysteria and diabetes.

I hope this letter has helped to clarify some of the misconceptions about the gender-affirming care model and transgender identities. I encourage you to review the sources I've cited and to continue engaging in respectful dialogue with your colleagues and clients. Together, I am certain we can work towards creating a more inclusive, supportive, and evidence-based mental healthcare system for all individuals, regardless of their gender identity.

Sincerely,

Ms. Lexi

DBT focused Licensed Mental Health Counselor