Behind closed doors: Gender doctors admit they are ‘winging it’ with minors

By Leor Sapir | The Free Press

In footage obtained exclusively by The Free Press, gender doctors acknowledge they perform life-altering procedures on vulnerable youth with no supportive evidence—and they are proud of it.

At their conferences, closed to outsiders and the press, the gender clinicians allowed themselves to speak freely. They spoke about the boys who said they wanted to be girls and the girls who felt they were meant to be boys, and the medical and surgical interventions that would make them appear as the opposite sex. The clinicians also discussed new procedures for a new type of patient—some of them adolescents—who wanted to be made to look as if they had no sex at all.

In one of the videos, obtained exclusively by The Free Press, from the 2021 conference of the US Professional Association for Transgender Health, Amy Penkin, a social worker with the Transgender Health Program at the Oregon Health & Science University (OHSU) spoke about one such case. Penkin told the audience about Sky, who she described as an 18-year-old recent high school graduate who was living on his own for the first time.

Penkin explained that Sky expressed a desire to look like “a Barbie down there.” Sky, Penkin said, reported “being asexual, never having had sex, and having no desire to have sex in the future.” Indeed, Sky did “not want to feel any pleasurable sensation and hope[d] removal of all erogenous tissue [would] be possible,” according to Penkin.

Not so long ago, a patient like Sky would have been given a psychological evaluation and offered mental health counseling. But in the evolving world of gender medicine, clinicians now want to help young people like Sky achieve their gender goals.

Penkin explained to fellow professionals that requests for procedures that are “nonbinary” are “growing in number.” But the field is still wedded to binary assumptions. This means that procedures such as “nullification” (surgically leaving patients with no external genitals) or “penile preserving vaginoplasty” (surgically crafting a pseudo-vagina underneath the penis) are not as accessible as they should be.

Penkin said that when confronted with a patient like Sky, existing “research” and “standards of care” are “not enough to meet the needs of our patients, and we need to take it to the next level to really think about how we evolve and match the needs of our patients as their needs are being expressed to us.”

Penkin’s colleague, psychologist Mair Marsiglio (she was identified as “Mary” in the video), agreed, and described doing just that. Marsiglio told the conferees that it’s “important to reframe the role of the mental health person or the psychologist as a collaborator rather than a gatekeeper.” That meant, Marsiglio explained, making sure that patients with serious mental health problems such as “multiple personalities” and “psychosis” are not excluded from gender surgery just because the team is “uncomfortable” operating on them.

Marsiglio said that being a member of the surgical team provided the opportunity to “help the patient. . . navigate care.” This is especially necessary, Marsiglio said, when what is requested by the patient is “a surgery that has not been performed before or is of higher risk.”

As for Sky, Penkin explained that the healthcare system still required minimal oversight, especially when seeking insurance coverage for procedures. Sky was able to obtain “two letters of support” from mental health professionals, according to Penkin, clearing the way for the teenager—who was legally an adult—to be castrated.

A Major Strategic Blunder

We know about the case of Sky, and other such young people, because of a lawsuit. And because of that lawsuit, The Free Press has obtained exclusive access to some of the recordings made at these conferences, the content of which are being made public for the first time.

In recent years, 27 states—almost all Republican-leaning—have passed laws that restrict or ban medical gender transition of minors. In 2022, Alabama’s Vulnerable Child Compassion and Protection Act criminalized such medical procedures. Advocacy groups including the Human Rights Campaign and the Southern Poverty Law Center immediately sued the state to overturn the law. This suit—Boe v. Marshall—became a major strategic blunder.

The plaintiffs urged the federal district court to rely on the expertise of the World Professional Association for Transgender Health (WPATH) and its American chapter, USPATH. WPATH was widely touted in the advocacy and medical communities as providing unassailable guidance, in the form of its “Standards of Care,” for how to provide treatment of young people with gender dysphoria—or distress over one’s biological sex.

The court agreed, and the materials obtained in legal discovery by the state of Alabama between 2023 and 2024 about WPATH’s methods and conclusions proved scandalous.

It was alleged that WPATH had suppressed evidence reviews by researchers who found that the supposed benefits of hormones and surgeries for minors were not based on credible evidence. WPATH was also accused of failing to manage or even acknowledge conflicts of interest, allowing clinicians to write medical recommendations favorable to their financial and other interests. Reportedly, it eliminated age minimums for hormonal and surgical interventions on minors for explicitly political reasons.

News of the misconduct appeared in the The New York Times, The Economist, The Washington Post, City Journal, and the prestigious medical journal The BMJ.

The litigation also resulted in Alabama obtaining hundreds of videos of conferences and other events put on by WPATH and USPATH. The videos provide a window into how gender clinicians, when they think outsiders aren’t listening, speak differently to each other from what they tell the wider medical community and the public at large.

For example, The Free Press and other publications have documented how families are pressured into approving the transition of minors with the unsubstantiated threat that a child will commit suicide otherwise. Or how false assurances are made about the safety and necessity of life-changing gender interventions, treatments that can cause many serious side effects, including infertility.

Last June, in another case that turned out poorly for the transgender advocacy groups, the Supreme Court ruled that state laws limiting youth transition were constitutional—thus ensuring a legal victory for Alabama. As the case by the plaintiffs against the Alabama law was coming to an end, representatives of WPATH urged the court to keep the videos under seal. They lost.

“Wing It Together”

One of the biggest revelations from the recordings is how these clinicians acknowledge performing unproven, seemingly experimental treatments—only it appears there is often no protocol being followed, no formal research being conducted, and no ethics-board approval being sought. These practitioners say their goal is to fulfill the “embodiment” desires of their patients, whatever these may be, and doing this may require “deviat[ing] from guidelines.”

To explain what it means to fulfill patients’ “embodiment goals,” pediatric endocrinologist Hayley Baines of OHSU’s Doernbecher Children’s Hospital gender clinic presented a “composite case” at the 2022 WPATH conference. Baines described a 13-year-old boy who identified as nonbinary (“she/they” pronouns) and whose “stated goals are: ‘I want tits,’ and ‘I want my parts to still work.’ ” The boy and his accompanying parent, who also identified as nonbinary, were both “surprised” to hear that hormones could compromise his future fertility. The clinical team’s role, Baines explained, was to understand how “impacts on fertility and the ability to have erections” fit in within the boy’s “goals.” When the boy responded with “c’est la vie,” the parent, who wanted biological grandchildren, started crying.

For some clinicians, a WPATH conference was a place to have a safe discussion about their concerns about performing novel procedures on vulnerable young people. They discussed how to protect themselves from the possible legal and other consequences of practicing at what one gender doctor called “the edge of medicine.”

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