Informed Consent Revisited

The WPATH files reveal just how bad the practices in gender medicine really are

Photo by Myriam Zilles on Unsplash

I have discussed the issue of the capacity of children to give informed consent to so-called gender affirming treatments such as cross sex hormones in two previous articles. The first was an analysis of a consent form for puberty blockers which a gender clinic at a Canadian hospital was sending to primary care providers so that they could start patients on puberty suppression before they were seen by a gender specialist. The second article discussed whether children and adolescents had the capacity to consent to treatments which would leave them permanently sterile. The WPATH Files report by Mia Hughes clearly shows that the actual practice of obtaining informed consent in gender clinics is much worse than I had assumed.

My article on sterilization referred to a presentation at a 2022 WPATH conference in which Dr. Daniel Metzger admitted that many of his young patients had no real understanding of what it meant to be sterile and that some of them regretted their decision in their twenties. Dr. Metzger is and endocrinologist from British Columbia who is one of the co-authors of the Canadian Paediatric Society position statement on gender affirming care, which appear a few months after my article. Dr. Metzger is quoted several times in the WPATH files on issues relevant to informed consent.

One of the first requirements of informed consent is that the patient understand the nature and effects of the proposed treatment. Critics of gender medicine are usually mainly concerned with the ability to children and adolescents to appreciate the life-long consequences of gender transition. However, Dr. Metzger says that many of his patients have a poor understanding even of the short-term physical consequences of hormones. Here is a transcript of an answer he gave at the 2022 conference:

Dan Metzger: I think, you know, when we, when we start people on, um, testosterone or estrogen, uh, you know, we, we try to be as clear as we can, um, about the stuff that's going to be permanent and the stuff that's, that's going to go backwards. So if you started testosterone, your voice is going to change. That's permanent, but you might get more muscly, but then that's not permanent if you were to stop.

Um, I think the thing you have to remember about kids is that we're often explaining these sorts of things to people who haven't even had biology in high school yet. And, and, um, uh, and I know I've, I've heard others in, in this kind of a, in this kind of a setting say, well, we think adults are like really slick biologically.

And in fact, lots of people have very little medical understanding of stuff like that. We just put medical professionals and. mental health professionals take for granted. So I think we have to be, um, more concrete than we think we need to be. Um, short of surgical stuff, you know, I think, I think, um, uh, and the permanent physical changes that happen with testosterone or estrogen, um, you know, you might get some breast development that maybe you would later regret.

Uh, but I think, um, it's reasonably safe to, to be on hormone X for a while and then stop and go back to your, to your natal hormones. Provided you haven't had some sort of a gonadectomy, then, as Cecile mentioned, that's a different issue if you're hormone less, um, so, um, I think that is important, um, for people to know, and I think we also, like, just in general, you know, people want this, but they don't want this, but they want this, but they don't want this from a hormone, and I'm like, well, you know, you might not be binary, but hormones are binary, and so, you know, you can't get a deeper voice without probably a bit of a beard.

It doesn't work that way, or you can't, um, you can't, uh, you know, get estrogen to feel more feminine without some breast development. It, that doesn't, that doesn't work very well. And there are different ways of trying to get around some of these things, but in general, um, you know, when you give a hormone, it's going to do what hormones do.

It's going to act on a receptor, the receptors are everywhere, and you're going to get some sort of a physiologic effect, and it's hard to kind of pick and choose the effects that you want. And, and I know that that's, um, I know that that's, uh, like something that kids wouldn't, wouldn't normally understand because they haven't had biology yet, but I think a lot of adults as well are hoping to be able to get X without getting Y, that's not always possible. [Emphasis added]

Dr. Metzger is concerned that his patients (or their parents) have not taken high school biology. He should be concerned that many high-school and even university biology students are being indoctrinated with the idea that sex is a spectrum. They have been taught to think of sex and sexuality as a continuous array of choices and they are unable to grasp the concept that some choices are binary.

Loss of fertility is one of the most serious consequences of hormones and puberty blockers and one which young patients have difficulty understanding. The Canadian Paediatric society position statement recommends discussing fertility preservation with patients prior to both puberty blockers and cross sex hormones. Here is the transcript of Dr. Metzger’s comments on fertility at the 2022 WPATH conference:

Dan Metzger: I, I was just gonna say, you know, like, like it's always a good theory that you talk about fertility preservation with a 14 year old, but I know I'm talking to a blank wall. And the same would happen for a cisgender kid, right? They'd be like, Ew, kids, babies, gross. Or, or the usual SPAC answer is I'm going to adopt. I'm just going to adopt. And then you ask them, well, what does that involve? Like, how much does it cost? Oh, I thought you just like went to the orphanage and they gave you a baby.

No, it's not quite like that. Um, but, um, and I was just trying to find it, but I can't, I can't quickly locate it because I only have is like a picture of a slide, but apparently last week at the Pediatric Endocrine Society, uh, some of the Dutch researchers started, uh, gave some data about, um, young adults who had transitioned and reproductive regret, like regret, and it's there.

Um, and I don't think any of that surprises us. I don't remember any of the numbers or anything. I just, again, I have a picture of a slide. But hopefully this is something that will get published in the next while. But, um, you know, I think, I think now that I follow a lot of kids into their mid twenties, I'm always like, Oh, the dog isn't doing it for you, right?

Yeah, they're like, no, I just found this, you know, wonderful partner and now we're kids and da da da. So I think, you know, it doesn't surprise me, but I don't know still what to do for the 14 year olds. The parents have it on their minds, but the 14 year olds, you just... It's like talking with diabetic complications with a 14 year old. They don't care.

They're not going to die. They're, they're going to live forever. Right? So I think, I think when we're doing informed consent, I know that that's still a big lacuna of, of that we're just, we do it. We try to talk about it, but most of the kids are nowhere in any kind of a brain space to really, really, really talk about it in a serious way. I, that's always bothered me, but you know, we still want the kids to. Be happy, happier in the moment, right?

Future sexual function is another aspect of puberty suppression that ought to be addressed in an informed consent process. Former WPATH president Dr. Marci L. Bowers says in a listserv post, “To date, I’m unaware of an individual claiming ability to orgasm when they’re blocked at Tanner 2.” This is the stage of puberty that occurs at about 11.5 years in males and 10.9 years in females but can start as early as age 9. Here is what Dr. Metzger had to say about starting children on puberty blockers at such a young age:

You know, I totally agree. And I'm sure putting a kid on a blocker at age nine, and then letting them get to the age of whatever, when they're developing a sexual identity, can that be. Uh, cannot be great, right? So I think I think that the other people brought this up that we are to a degree robbing these kids of that sort of early to mid pubertal sexual stuff that's happening with their with their cisgender peers.

That's not happening because we've got the one loop running and their you know, their brains are just not thinking that way. There's no, you know, they're getting older and smarter about, you know, math, but they're not learning how their body works. They're learning how to masturbate because they don't, because they don't have the urge to do that, right?

And all of a sudden they're, you know, they're, they're way many years behind their peers trying to like figure their sex stuff out.

This is an admission that puberty blockers do have irreversible effects on a child’s development that a child is simply incapable of understanding.

There is much more in the files and the report which is relevant to informed consent. WPATH members discuss serious complications of both hormones and surgeries which are neither being researched nor disclosed to patients. There are discussions on approving patients for hormones and surgeries despite serious physical and mental health conditions.

The most disturbing aspect of the discussion is that the whole concept of promoting health seems to be absent. Instead, the doctors all talk about helping patients pursue their “embodiment goals.” This is the case even for children and adolescents. The clinicians in the discussion seem to be perfectly aware that children and even adolescents have difficulty setting stable and rational long-term goals. They are also aware that the treatments they are prescribing can have permanent effects and serious side-effects which their young patients are not able to understand.

Some of the essential requirements for informed consent to puberty blockers and cross-sex hormones are not being met in the case of young patients but doctors are proceeding with treatment. More of these patients are reaching the age of majority and the legal implications of what has been done are likely to occupy the courts for many years.