An Ob/Gyn Reports on “The Dangers of ‘Gender Affirming Care’ for Minors” Part 2

This is the second part of my reporting on the July 8 Federal Trade Commission workshop at which they announced they were planning to investigate a number of mainstream medical organizations – the World Professional Association for Transgender Health, the American Academy of Pediatrics, the Endocrine Society, and the American Psychiatric Association were all named – for consumer fraud.

This is a sentinel event for the American medical system. Whether physicians agree or disagree with the points of view the FTC presented at this workshop, it is in all of our best interest to be familiar with the discourse. Here is Part 1.
Picking up where we left off, after an emotionally grueling panel of former pediatric gender medicine patients and their parents, we turn our attention to…

Dr. Miriam Grossman

Dr. Grossman is a psychiatrist boarded in adult and child / adolescent psychiatry. She is also a senior fellow at Do No Harm Medicine, which is one of several physician organizations that question current mainstream guidelines on gender medicine. Do No Harm is on the socially conservative end of the spectrum. It opposes DEI in medicine as well as “gender ideology.” Just to provide some context.

First, Dr. Grossman gives the definition of fraud in the FTC act: “Representing as facts things that are entirely unproven or demonstrably false, thereby misleading the consumer in a material way.” She states that gender affirming care meets this definition.

She alleges that, “Gender specialists took the results of one tiny Dutch study, whose subjects were carefully chosen, and led parents to believe that every child distressed about their sex could benefit from that model of care.” She alleges that although families are told there is consensus among clinicians on this care, it is in fact “silencing of opposition.” She describes three areas of deceptive practice: in language, medical records, and therapist letters of support.

Regarding language, she states that humans have two sexes, established at conception, and that sex does not change and cannot be changed. She cites a slide on acceptable language from the Kaiser system, such as “gender affirming surgery” in lieu of “sex change operation” and “assigned male at birth” in lieu of “born male.” She calls this control of language Orwellian and fraudulent.

She states that telling a patient they have “a girls’ brain in a boy’s body” is fraudulent if represented as factual, since this assertion is as unproven and unprovable as the existence of a soul is. She argues that young people, after hearing this language, genuinely think doctors can turn them into the opposite sex. On showing a screenshot from the Johns Hopkins website, which states, “Gender affirming surgery can be used to create a vulva and vagina,” she says, “Boys see this and think they can get an actual vagina and be a woman just like any other.”

She also makes the point that the social transitioning of children increases the odds that gender dysphoria will persist beyond adolescence, and parents are not informed of this when they are advised to use their child’s preferred pronouns. She states the term “sex assigned at birth” is designed to change the way we think about male and female – that sex is not an inherent quality of all the cells in our body,

She alleges that “Top surgery” and “bottom surgery” are dangerous euphemisms, made to distract from what they really are, the removal of healthy organs.

She alleges that changing a patient’s sex in the medical record is fraudulent and provides many examples of such patients. She cites examples of patients whose emergency department providers did not realize their biological sex, and thereby did not consider conditions such as pregnancy, which led to their deterioration.

She also describes the practice of submitting claims for lab tests and medications under the ICD-10 code e 34.9, “Endocrine disorder, not otherwise specified” for patients with gender dysphoria, in order for insurance to cover this care. She states that these patients have a psychiatric diagnosis, not an endocrine diagnosis, and therefore the diagnosis is fraudulent.

She states that letters from therapists clearing patients for hormonal or surgical treatment for gender dysphoria may be fraudulent when they ignore a patient’s obvious unresolved mental health problem. Typically, it is required that all other mental health conditions be stabilized prior to starting medical therapy for gender dysphoria. She gives several examples of therapists who describe active and severe psychiatric problems in the patient’s chart but write on the same day that all mental health problems are well controlled in the clearance letter for treatment.

Panel 2: The Politicization of Science

Annie Chiang, an attorney with the FTC, facilitates this panel, and introduces it thusly:

“This event felt impossible not too long ago. For most of recent history, asking these questions has been forbidden in many circles. How did this happen? How did politics and ideology capture this area of medicine?” Quite frankly, I have had the same questions and was looking forward to these panelists’ thoughts.

Leor Sapir, PhD, a fellow at the Manhattan Institute (a generally conservative think tank), had some truly excellent insight. For a non-physicians, he really seems to get us, our culture, and how medical knowledge is created.

First, he states that, “There is a growing acknowledgement among educated class that something has gone very wrong with gender medicine, that there is this child-led model where no assessment takes place and kids are rushed into treatment. However, it is always accompanied by another claim that there is a careful way to do youth gender medicine. Even this supposedly more conservative approach has been found to be based on very low quality and uncertain evidence. There is still no good way to know which kids may benefit. Even if you could, there are still significant ethical problems about informed consent, because no 12 year old knows what it is like to give up sexual function, fertility, and potentially cognitive function.”

Going into the origins of this situation, he describes the “chain of trust” that is integral to our modern, specialized medical system. Essentially, we trust our colleagues in other fields to do a good job in their specialty, and we expect deference from them about how to operate in our own fields. This is true. I would not expect to tell a cardiologist which stent to use, and I would be furious if a cardiologist tried to tell me whether an ovarian cyst should be removed. Nor do we have any interest in getting involved in each other’s fields. We have enough to do, and I trust the cardiologists. However, Sapir says, “That trust can be abused, and pediatric gender medicine is a prime example.”

The leading authority on gender medicine in the United States is the WPATH. Its most recent guidelines, the Standards of Care 8, came out in 2022. Sapir says, “WPATH has managed to embed its SOC and approach to understanding gender and human nature in every aspect of US health care” -- in what insurance covers, trainings for hospital staff, integrating WPATH standards into residency education. “About 20 medical associations, including the AMA, have reassured regulators that these standards are credible and deserve deference.”

Sapir takes us back to 2012, when WPATH issued it’s 7th edition of the Standards of Care. Its leaders acknowledged then that the SOC 7 did not meet the high scientific standards of evidence-based medicine, in that it was not based on systematic reviews (a methodical and precise way for researchers to aggregate many different studies). WPATH wanted the credibility of a systematic review-based guidelines, so when they decided to embark on the SOC 8 edition in 2017, they hired research experts at Johns Hopkins to do a number of systematic reviews, in particular about pediatric topics.

However, as Sapir tells it, the researchers at Johns Hopkins found that the evidence behind a number of the guidelines was very weak. So WPATH leaders prevented the researchers at Johns Hopkins from releasing the research. Instead, the SOC 8 stated that, “a systematic review was not possible.”

This is unbelievably shady on the part of WPATH. This should not have happened. I cannot emphasize how wrong this is. In science, if you test a hypothesis, and your hypothesis is proven wrong, you do not bury the results of the research. You take the L and add to our collective scientific knowledge.

The (paywalled) article breaking the news in the lay press is here: https://www.economist.com/united-states/2024/06/27/research-into-trans-medicine-has-been-manipulated

Sapir further alleges that WPATH stacked the guideline panel with people who are “personally and professionally invested in medical transition,” eliminated age minimums for transition procedures for political reasons, and admitted to putting in medical necessity statements to win insurance coverage and legal battles. In doing so, Sapir says, WPATH committed fraud against patients, their parents, the American public, the medical community, insurance companies, medical association leaders, hospitals, and individual clinicians.

Sapir also calls out the American Association of Pediatrics for inaccurate guidelines. The AAP’s most recent policy statement on “Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents” was published in 2018. The statement is indeed largely supportive of expansive youth medical and surgical gender transition. According to Sapir, it has been criticized for having errors and misrepresentations, but the AAP has refused to engage with criticisms, dismissed critics as “transphobic,” and silenced its own members. The AAP decided in 2023 to review its guidance, and no information about the status of this process is available publicly.

Finally, Sapir states, the Endocrine Society released clinical practice guideline for youth gender medicine in 2017, making strong recommendations for puberty blockers and cross-sex hormones. He states that the members who wrote the statement are gender clinicians and members of WPATH.

Sapir calls this strategy of using other medical societies to issue their own guidelines affirming WPATH’s standards “credibility laundering.” He argues that medical leaders assume that since something is peer reviewed, it is credible. (I agree with this, because in general, it is.) Sapir also cites a climate of intimidation activists have created, so that medical professionals are afraid to openly discuss their views, and people are vilified on social media.

This is true. I have had many physicians write to me saying that they support my opinion on gender medicine but are afraid to say so publicly. They have not told me exactly what they are afraid of, but I believe it is being publicly denounced as a bigot. Bigotry is truly one of the worst accusations a medical professional can face and can be career ending. Accusing those who are concerned with the current standard of care of bigotry has been an extraordinarily successful tactic.

Moving on, after that very insightful talk, we have:

Dr. Ethain Haim, a general and trauma surgeon from Texas. He has a very interesting back story. There are many allegations on all sides of this situation. You are all very lucky, because I don’t really have a dog in the fight about whether Dr. Haim violated HIPAA, I have gone through literally dozens of HIPAA trainings in my life, and I am going to delve into it right now.

In March 2022, Texas Children’s Hospital announced it would stop providing gender-affirming hormone therapies after some drama whereby Governor Abbott directed Texas’s child welfare agency to investigate such care as “child abuse.” (n.b. I do not think using this kind of language, or accusing loving parents who are trying to do the right thing for their kids of “child abuse,” is helpful to anyone except grifters trying to stir up drama for likes on social media and political reasons.) The Washington Post covered it. The article didn’t give a time frame but implied the decision was effective immediately.

Then, a conservative activist named Christopher Rufo published evidence given him by an anonymous whistleblower that doctors at Texas Children’s had continued to provide hormonal treatment to gender dysphoric youth through 2023. Of note, youth gender medicine was still legal in Texas at the time. However, after these revelations, the Texas legislature quickly passed a ban. The FBI got involved because of possible HIPAA violations and identified Haim as the leaker. (Although, really, Texas Children’s IT people could have easily identified him without the FBI’s help. Every move we make in the electronic medical record is tracked.)

Although the documents are no longer available, Dr. Haim claimed that he redacted all protected health information from the documents he gave Rufo. I believe this, because you would have to be a complete idiot not to, and Dr. Haim is not an idiot. So Dr. Haim did not violate HIPAA by giving the documents to Rufo, because all patient information was presumably de-identified.

However, he did access the medical records of patients he was not personally treating, and he did access them under false pretenses (asking for his login to be restored so he could allegedly see pediatric records of his actual patient, which he did not do). This is a HIPAA violation, and I have definitely known people to be fired over this – looking through records for idle curiosity because patients were in the news or whatever. Although it is not a good look for Texas Children’s to have lied about what they were doing, Dr. Haim is not in law enforcement and did not have a warrant to look in the records, and he did not attempt to go through official channels.

Verdict: this is technically a HIPAA violation. However, I do not think he deserved the investigation by the Biden administration, in which they tried to put him in prison for 10 years for looking in those charts. I don’t think anybody went to jail for 10 years for looking in Britney Spears’ chart when she was hospitalized, although they did all get fired. Nor do I believe the FBI got involved. So the punishment was clearly politically motivated for retaliation and intimidation. We’ll just say Dr. Haim is an outlaw with a heart of gold.

Anyway – Dr. Haim spoke and alleged that, “The institution of medicine has been taken over by radical left-wing ideologies. People who spoke up were increasingly vilified. They would be fired, held back from promotions, sometimes targeted by governing authorities in their states. All the people who are promoted and teach residents and medical students cannot have conservative or even middle-of-the-road views. Being an average person precludes you from being hired at a prestigious academic center.”

Since I am just a country obstetrician from Iowa, I cannot confirm or deny. It’s probably true in some places. You can be full MAGA and be the chair of the department around here, trust me.

Edmund LaCour – LaCour is the Solicitor General of Alabama. He is here because Alabama passed a ban on youth gender medicine. LaCour says that, when all these state bans were being passed, the ACLU and other activists would challenge the state bans and request emergency injunctions. They would tell judges that the banned care was evidence-based and supported by guidelines, and that children were at risk of suicide if the injunctions weren’t granted. Because of this argument, Alabama was able to obtain documents from WPATH about how their guidelines were crafted in legal discovery. LaCour was shocked by what he found.

In 2022, the WPATH issued their new guidelines, the SOC 8. The guidelines were published via the WPATH website and contained age minimums for various treatments. (14 for testosterone or estrogen; 15 for mastectomy; 16 for breast augmentation and facial surgeries; 17 for hysterectomy, vaginoplasty, or oophorectomy; and 18 for phalloplasty) Soon after the guidelines were published, they disappeared, and then a new version was published without the age limits, and the reason was not publicly known.

However, due to the documents uncovered by the state of Alabama (link, and honestly they are disturbing – I recommend checking them out), it was because Admiral Dr. Rachel Levine, a Biden administration official, a transgender woman herself, and a vocal advocate for gender medicine, had requested the changes from WPATH for political reasons, thinking that age minimums would encourage more bans on youth gender medicine.

LaCour notes that because of time constraints, the removal of the age minimums did not go through something called a Delphi process, which I am admittedly not familiar with, although the SOC 8 claims they did.

LaCour also notes that best practices for crafting medical guidelines are that a minority of people involved should have a vested interest in the outcomes. However, the majority of the SOC 8 creators had a vested interest. In fact, Dr. Marci Bowers, who is also a transgender woman and the president of WPATH, has stated that everybody involved in the guideline development should be “an advocate for expansive transgender care.”

LaCour also brings up the emphasis on “embodiment goals” as the end point for medical treatments, saying that “wants are being treated as needs,” and that there is no concrete evidence the treatments are in reality “medically necessary,” as is clamed.

He also brings up the WPATH chapter on eunuchs, which I will provide a link to here. Just scroll to chapter 9. No comment is really needed.

Anyway, LaCour recounts that the Biden administration had sued Alabama over the law, but when these documents were received through discovery, sealed to the public at that time, they dropped the case. LaCour speculates it was because they hoped to keep the documents secret, since they were so damning. But Alabama was ultimately allowed to reveal them.

Jordan Campbell - Campbell is a Texas attorney who founded a law firm dedicated to representing detransitioners. He says he has heard from hundreds who wish to sue their gender practitioners, but due to the statute of limitations, most are unable to.

In talking about his clients, a few common themes they report are the “dead son or live daughter” trope, as well as “very fraudulent” form letters from therapists approving patients for hormonal treatments and surgeries without a true evaluation. He says that it has blown his mind that “institutions had this unquestioned rush to affirmation with zero guidelines.” For many of his clients, the first time they met a clinician, they were prescribed cross-sex hormones, puberty blockers, or both. “They don’t even follow WPATH guidelines,” he says.

Strategies for stopping fraudulent gender medicine

Chiang, the moderator, asked the panelists how to stop fraudulent youth gender medicine.

Dr. Haim suggested that using fraudulent diagnostic codes is a crime.

Campbell said that the pendulum on this issue is swinging, and truth will win out.

Sapir said that we need an “off ramp” for medical professionals who have been “caught up in this,” without demonizing them. He also advocates for understanding and compassion for kids and families who have “crossed the Rubicon” and medicalized.

LaCour said, “Some folks in the medical industry have been tricked, and some are doing the tricking.”

Again, I think this article is long enough for today. I don’t agree with everything every panelist said, but the revelations about how WPATH created its SOC 8 are pretty shocking, although at the same time they do explain how weird they are. The fact that the FTC is credibly accusing a major medical organization of fraud is just… how did we get here? If anybody thinks that the creation of the SOC 8 was not fraudulent based on the above information, I am open to that opinion, but I would like you to explain it to me like I’m stupid, because I don’t understand.

I will continue to report on the remainder of the workshop. Stay tuned for Part 3 (and maybe Part 4?), in which we get some more insights, including from whistleblowers who worked in the clinics themselves.