I performed my first gender-affirming hysterectomy with pride. It was 2019, and I was delighted to be my local LGBT clinic’s official gynaecologist. There is, after all, no greater joy in medicine than providing great care to a vulnerable, under-served community in Iowa. This was, I felt, how the world should be.
Six years later, I’m not so sure.
The hysterectomies went well. They were uncomplicated, and no one told me they regretted their surgery. But even though we were earnest, well-meaning clinicians, were we doing the right thing?
In 2019, I took a job as an Obs and Gyny doctor at a nonprofit in Iowa, after my private practice went out of business. I had a wife, twins in preschool, and a toddler. And, after working for a Catholic organisation previously, I loved the progressive policies of my new employer. They provided medical transition services for transgender patients and even sponsored an out-of-hours LGBT clinic for patients who might not have felt comfortable in a mainstream doctor’s office. I was at the clinic, enthusiastically, once a month to provide my expertise.
I was quite surprised, though, that the clinic seemed almost exclusively T, without much LGB. Call me naive, but for the past decade, I had my head down: training, getting married, having kids and starting my practice. And by the time I looked up, the LGBT world was very different from the last time I had really been around other gay people.
I also had some uncomfortable questions: hadn’t we learned in medical school that most paediatric gender dysphoria resolves by adulthood? If so, did it make sense for young adolescents to transition to the opposite sex? Was it really plausible that transgender female athletes didn’t have a biological advantage over natal females? The accepted answers seemed counterintuitive to me. Nonetheless, I was on board, assuming that the experts who crafted medical society guidelines around gender medicine had followed the usual process, carefully weighing the evidence, and had reached a scientifically based consensus before making their recommendations regarding gender medicine.
And so, for a few years, I became the go-to gynaecologist for gender-affirming hysterectomy referrals and other gynaecology care for transgender patients. Although this was a very small part of my practice as a full-scope Ob/Gyn in a rural underserved area, I loved it. I enjoyed taking care of my patients. Some would drive hundreds of miles from their homes elsewhere in rural Iowa to receive their care with us. I was, I felt, providing a much-needed service. The patients came in knowing exactly what they wanted: a hysterectomy. Unlike hysterectomies for abnormal bleeding or pelvic pain which require full diagnostic tests, there was no need to document prior attempts at treatment, failures, and impact on the patient’s life. “Gender dysphoria” always got approved (with the requisite two letters, one from a mental health professional and one from a PCP). Unless they had a major contraindication, such as uncontrolled diabetes, we could just book them in.
Of course, I counselled my patients. Would they like their ovaries conserved or removed? I was adept at discussing the risks and benefits of both approaches. I offered referrals for egg freezing if they desired oophorectomy. I discussed surgical risks and expected recovery. But these surgeries were still, I would joke to my assistant, “my easiest consult of the day”.
But as the years went by, I couldn’t help but notice some troubling trends. The trans patients who came to me had more and more mental health complications. I also started seeing a fair percentage of them who were really quite feminine — not very different in their gender presentation from my biologically female patients.
Then came the see patients who truly stymied me. One who particularly struck me was just 21 years old, born a female but who now identified as nonbinary. They requested a hysterectomy to conform to what they saw as their gender identity, but otherwise did not desire transmasculine medicalisation such as testosterone or mastectomy, and had classically feminine mannerisms and dress.
I began to feel more uneasy that hysterectomy — surgery that carries numerous surgical risks, and results in irrevocable lifelong infertility — was necessarily the right thing for this new group of trans patients. But if they didn’t have any contraindications per se, I couldn’t really say no. After all, according to the American College of Obstetricians and Gynecologists, a hysterectomy is “medically necessary for patients with gender dysphoria who desire this procedure”.
I thought the World Professional Association for Transgender Health (WPATH) guidelines might help my dilemma. But as I puzzled over the “nonbinary” section, I found no clarity. The guidelines said that “motivations for accessing (or not accessing) gender-affirming medical interventions, including hormone treatment, surgeries, or both are heterogeneous and potentially complex and should be explored collaboratively before making decisions about physical interventions”. Though that seemed like solid advice, I did not feel particularly well equipped to do so as a surgeon, rather than a mental health professional.
Still wondering how best to take care of my patients, I went on a private online forum for O&G doctors to ask about how others addressed nonbinary individuals who requested gender affirming hysterectomy. I was told my question was “transphobic”. I was told that the surgery was “life saving” (presumably due to the suicidality brought on by the presence of one’s natal uterus).
This didn’t sit well with me. I wondered about one of my patients, who had detransitioned just a few years after her hysterectomy. Conventional wisdom said detransition almost never happened; that the rate was just 1%. Well, I certainly hadn’t done a hundred hysterectomies for gender affirmation. So what was going on here?
Curious as to whether detransitioning was more common than we thought, I found my way to Hannah Barnes’s excellent book, Time to Think, which detailed the scandal at Britain’s national youth gender medicine clinic, the Tavistock Centre. Barnes found that distressed adolescent girls with no longstanding history of gender dysphoria were requesting to become boys at skyrocketing rates and being prescribed puberty blockers and testosterone with very little medical or psychiatric evaluation, while any adults raising concerns were labelled “transphobic”.
“Any adults raising concerns were labelled ‘transphobic’”
Similarly, through reading Jesse Singal’s work on the scientific basis of youth gender medicine, I learned about the relatively flimsy evidence it is built on. Certainly, there have been studies that seem to show favorable short-term mental health outcomes for youth who access gender medicine. But there have also been scandals about burying the outcomes of major studies at Johns Hopkins and Children’s Hospital of Los Angeles. It seems nobody has published a long-term study on how these young people are doing. In fact, the Tavistock in London, which was forced to close, failed to retain or share data on thousands of children. It seems that nobody knows the true rates of detransition for young people, but according to the most credible expert in the field, Dr Kinnon MacKinnon, who is himself an openly transgender man, “it is very unlikely to be only 1%”.
I was surprised that in America there were no specific requirements for the psychological evaluation of young adolescents before it was agreed that they were ready to start transitioning. WPATH guidelines say that the young person should have demonstrated “a marked incongruence between one’s experienced/expressed gender and assigned gender, of at least six months’ duration”, but in practice, even this minimum requirement has not consistently been followed. Even the minimum standard of a basic mental health evaluation of the patient, as advised, is controversial. Dr Johanna Olson-Kennedy, president-elect of the US division of WPATH, has been an outspoken advocate of the “informed consent” model, deeming the requirement of any psychological evaluation prior to starting a medical transition to be excessive gatekeeping.
And while things are changing in Britain, where puberty blockers are no longer allowed for under-18s, there are many youth gender clinics in America which routinely provide prescriptions for puberty blockers or hormones at patients’ first appointments, even when a patient does not have a longstanding history of gender dysphoria since early childhood.
I also discovered an emerging population of detransitioners, individuals who took steps to medically transition and who have now reverted to their natal gender identity. Although some do not regret the changes they made to their bodies, others are profoundly distressed by them and have serious and credible critiques of the gender medicine system as it stands.
I had just assumed the experts crafting guidelines were ensuring that there was a body of evidence supporting the incontrovertible long-term benefits for these extraordinary treatments that were being performed on young people: puberty blockers, cross-sex hormones, and double mastectomy.
However, since there was no unbiased scientific organisation of experts on transgender issues, American medical organisations relied on WPATH to guide them. Why wouldn’t they? As upstanding evidence-based scientific organisations, they generously assumed their counterparts were the same. But the holes in the evidence behind WPATH’s official standards of care become more obvious, suggesting that these organisations can rely only on themselves to evaluate the evidence. Interestingly enough, the American Society of Plastic Surgeons conducted its own review of the evidence, and, contrary to the interests of its own members, concluded that gender affirming mastectomy for minors is not ready to be rolled out.
Let me be clear. I understand that the profound psychological pain of gender dysphoria is real. And many adults have found happiness after medical transition. But what isn’t clear is whether medical transition for adolescents still developing their identities is the solution that many hope it is. A 2024 study from Finland — a progressive nation, with a strong social safety net and a tradition of women’s rights — found that medical transition in gender dysphoric adolescents did not decrease the risk of suicide.
After all, is it really credible that gender dysphoric adolescents, who we know have existed across societies for millennia, have recently become distraught to the point of widespread suicide because they could not access puberty blockers, cross-sex hormones, or mastectomies — none of which was available anywhere in the world until the first youth gender medicine clinic opened in the Netherlands in the Nineties? This is a serious claim. If it were true, of course, medical and surgical transition should be available to any gender dysphoric adolescent who desired it. But the evidence that medical transition itself — rather than the compassion and acceptance the patients find in a youth gender clinic — prevents suicide, is truly scanty.
In medicine, sometimes we get ahead of ourselves. New treatments which seem so promising at first don’t always work. The widespread prescription of oxycodone as a panacea for chronic pain in the 2000s is a good example. The doctors who prescribed it wanted to help their patients, but just didn’t realise the real harms caused by oxycodone until they became common enough to see.
I’d like to believe that we are people of science who realise when it is time to course correct. On gender medicine, the time is now.
It is time for experts in our professional organisations need to make evidence-based recommendations for standards of care. We need to seriously ask ourselves what the safest, least harmful interventions are in youth gender medicine, and hold these interventions to rigorous, data-driven standards. It may be reasonable at this juncture to halt new medical and surgical treatments for minors (puberty blockers, cross-sex hormones, and mastectomies and other surgeries) outside of well-designed, lengthy clinical trials. It is time to provide resources within the institutions of mainstream medicine for people who seek detransition care.
And to question whether “gender dysphoria” as an indication in and of itself for hysterectomy, without abnormal bleeding, pain, or any other diagnosis, should continue to bypass all of the checks and balances in our healthcare system for major surgery. My fellow gynaecologists, if we are people of science who know right from wrong and care about our patients, we can surely find the courage to do this.
This is an edited version of a piece first published on The Ob/Gyn Power Project.
