Last week, a therapist named Tamara Pietzke went public in The Free Press with disturbing allegations against her former employer, the MultiCare health system, and its pediatric hospital, Mary Bridge, in Washington State. Pietzke described an environment in which kids with severe mental-health problems and histories of sexual trauma and abuse were being put on a fast track to “gender-affirming” hormonal interventions. Clinicians with doubts that body-modifying hormones were the best way to help these children were silenced and asked to “examine [their] biases.”

In her article, Pietzke describes one case in particular, involving a young girl whom I’ll call “Ava,” as “one of the most extreme and heartbreaking” she had ever seen. The case illustrates three troubling features of the gender-affirming model: its use of a “minority stress” theory to cast severe trauma, mental-health problems, and neurocognitive challenges as irrelevant to decisions about hormonal treatments; the pipeline from first contact with a mental-health provider to the endocrinologist’s syringe; and the willingness of “affirming” providers to shirk the very medical guidelines that they claim to follow, at least when following them would mean not approving a teenager for hormones.

Additional details about what went on at MultiCare—details that have not yet been made public—are critical for understanding the sordid realities of “gender-affirming care” in the United States. Pietzke has shared with me e-mail communications she had with her supervisors and colleagues. These e-mails give valuable insight into the institutional support for a model of care that lacks even the most basic of safeguards.

Ava was 13 when she came to see Pietzke. She had been experiencing distress about her sex for about a year. She was diagnosed with depression, post-traumatic stress disorder, anxiety, intermittent explosive disorder, and autism. Ava was barely able to communicate verbally, likely because of her autism, and seemed not to have any comprehension of the meaning of her appointment at the Mary Bridge gender clinic. In fact, according to Pietzke’s communications with her colleagues, Ava “did not express any gender distress or desire to transition in our sessions together.” She did, however, talk about the “Xenogenders [s]he identifies with. ‘It’s something autistic people made up. If you like a food, for instance, there’s a gender for it.’”

Ava’s past was saturated with abuse, neglect, and sexual violence. As a child, she had been sexually abused by a cousin, her mother’s former boyfriend, and a classmate. She told Pietzke that “horror and porn movies . . . were the only ones available in her house,” and that her mother “practices bestiality.” The mother had tried to kill Ava’s sister, who was also “questioning her gender,” in front of Ava, and now had a restraining order against her. The father was out of the picture, but the request to put Ava on testosterone came from him. The sisters, meantime, were being raised by the mother’s ex-boyfriend.

During therapy sessions, including on the first visit, Ava would rock back and forth and communicate with Pietzke by showing her “extremely sadistic and graphic pornographic videos on her phone.” The 13-year-old’s trauma was so severe that she would occasionally “age-regress” at home “by watching Teletubbies and sucking on a pacifier.” If there was ever a teenager whom even the most ardent of “gender-affirming” clinicians could agree is not a good candidate for medical transition, surely it was Ava.

Yet the Mary Bridge gender clinic approved Ava for testosterone on her first visit. Pietzke was incredulous. Ava had been all but incapable of verbal communication during sessions. How could the clinic possibly be confident that she understood the risks and uncertainties of hormonal treatments, even assuming these were forthrightly communicated to her? When Pietzke asked the clinic whether Ava had shown a clear understanding of what was going to happen to her, it abruptly assured her that everything was fine.

To receive hormonal interventions, adolescents must get a letter of support from a mental-health provider, confirming that they are in a stable state of mind and have no mental-health contraindications. In 2022, a social worker at the Mary Bridge gender clinic who is credited with increasing its patient caseload by 700 percent since arriving in 2019 said that the clinic conducts two assessments: a physical assessment, which involves lab work, and a “readiness assessment.” As the social worker explained, the point of the readiness assessment “is basically to break down any barriers, we try not to make it an additional barrier . . . We want to make sure . . . that when [patients] start gender-affirming care they can stay on it as long as they want to and we’ve addressed anything that would get in the way of that.”

Given the clinic’s avowed determination not to be “an additional barrier,” the only thing that can stop an adolescent without physical contraindications from being put on hormones is the absence of a letter of support from a mental-health provider. The staff at the Mary Bridge gender clinic made sure to instruct Ava to go to an “affirming” therapist for such a letter.

Pietzke considers herself an affirming provider—by which she means that she strives to create a safe environment for adolescents to express their feelings about gender. In her communications with colleagues, Pietzke would refer to Ava with male pronouns. She still uses “gender assigned at birth” when referring to sex. Yet her clinical judgment told her that Ava needed therapy, not hormones. On November 9, 2023, Pietzke sent an e-mail to Amber Rolfe, a therapist who oversees MultiCare’s gender program and serves on MultiCare’s DEI committee, the Belonging Advisory Council. Pietzke copied her supervisor on the e-mail.

Pietzke informed her colleagues of Ava’s troubled past, her ongoing mental-health and neurocognitive challenges, and the fact that she no longer attended school due to “being kicked out repeatedly” after threatening to kill herself and others. Pietzke “genuinely . . . want[ed] to do what’s right for [her] clients,” but she knew other countries had conducted comprehensive evidence reviews and were now taking a more cautious approach. The United States, she wrote, “does not have very good evidence” to support hormonal interventions. “From what I can tell, patients like the one I’m writing about are no longer offered hormonal treatments in these [European] countries.”

“I support transgender people and affirm them in who they are,” Pietzke continued, “but from what I’ve learned, there are many different reasons a patient can feel gender dysphoric. Additionally, given the health risks of testosterone therapy, I don’t want to sign a letter of support unless I know it’s the least invasive way to help this patient.”

Testosterone is a powerful agent. Some of its effects on the body are irreversible, and using it at the dosage required for sex-trait modification can lead to medical harm. Girls can experience irreversible changes to their voice, clitoral enlargement and chafing, atrophy of the vaginal walls resulting in severe pain and bleeding during intercourse, and chronic uterine pain that in some cases makes patients decide to get a hysterectomy. “My professional judgment,” Pietzke wrote, “tells me that my patient’s problems did not arise because of gender and will not be resolved through hormone therapy.”

In a training session on “gender-affirming care” she led a few weeks before receiving Pietzke’s e-mail, Rolfe had made it clear that therapists must always “affirm” their client’s “gender identity.” MultiCare, she emphasized, would tolerate nothing less. Pietzke wondered what, exactly, this meant. Was she supposed to set aside her clinical judgment and advocate hormones even for patients like Ava? What does it mean to be an affirming therapist?

Rolfe responded to Pietzke a few hours later. “I do want to share that we are going to disagree on the appropriateness of the writing a letter of support for this client,” she wrote, adding a smiley face. “While the trauma history reported is significant, there is no evidence that would suggest trauma contributes to folks misattributing their gender identity. I disagree with your understanding that gender affirming care is not well researched or that countries who have made recent changes are doing so based on research. There is a lot of research, and the medical and psychological communities have reached a consensus that gender affirming care is beneficial.”

Rolfe cited 25 professional U.S. health-care associations, the World Health Organization, and the Department of Health and Human Services, implying that all of these organizations would support a decision to approve Ava for testosterone. As for Pietzke’s mention of the changes in pediatric gender medicine abroad, Rolfe insisted that these were not due to “consensus of the medical and psychological communities” but to “political parties who use biased and disputed research to back their claims.”

Rolfe’s claims about changes in the treatment of youth with gender dysphoria in Europe are demonstrably false. Health-care policymaking in centralized welfare states like Finland and Sweden is usually more insulated from political pressures than in the United States, where doctors’ interest groups like the American Academy of Pediatrics and drug and medical device companies play an outsize role. Finnish and Swedish health authorities each conducted systematic reviews of the evidence and began revising their pediatric gender medicine policies when the Finnish Social Democratic Party and the Swedish Social Democratic Workers’ Party, both on the center-left of the political spectrum, were in power.

I asked Linda Hart, a liberal Finnish sociologist who closely follows the gender-medicine debate, about Rolfe’s characterization of what happened in her country. “Absolute rubbish!” she said. When COHERE, the body entrusted to assess health-care quality in Finland, issued its guidelines in June 2020, Hart noted, “the chairpersons of the Left Alliance (Li Andersson) and the Greens (Maria Ohisalo), who were ministers in [Prime Minister] Sanna Marin’s Social Democrat government at the time, expressed their disappointment in the guidelines for ‘creating barriers’ and decentralizing psychological support.” Hart emphasized that “politicians cannot direct what [a] body of experts is going to issue as guidelines and cannot change the guidelines.” 

The next statement in Rolfe’s e-mail captures the true spirit of the “affirmative” approach, especially regarding its use of the “minority stress” theory. “Trauma history is not a counterindication of [hormone replacement therapy],” she wrote. “There is not valid, evidence based, peer reviewed research that would indicate that gender dysphoria arises from anything other than gender. . . . The diagnosis centers on an incongruence of gender identity and assigned gender at birth.”

It’s not clear what Rolfe meant by the circular claim that gender dysphoria is only caused by gender. I reached out to her for clarification but received no response. Nor is Rolfe correct that “incongruence of gender identity and assigned gender at birth” is sufficient for a gender dysphoria diagnosis, according to the DSM-5. She probably had in mind the World Health Organization’s ICD-11 classification of “gender incongruence,” which, unlike the DSM-5’s “gender dysphoria,” focuses on the mismatch between perceived and actual sex and not on the accompanying distress or difficulty functioning.

As far as Rolfe was concerned, a teenager having a subjective sense of “gender” that is different from his or her actual sex is enough to allow—or rather compel—therapists to sign off on hormonal treatment. In this, her view seems to accord with that of the author of the American Academy of Pediatrics’ policy statement on “gender-affirming care,” who has said that “the child’s sense of reality and feeling of who they are is the navigational beacon to . . . orient treatment around.”

Rolfe concluded by chiding Pietzke on her choice of language. It was not enough that Pietzke used male pronouns when talking about Ava. “Describing clients as ‘natal; female’ or ‘natal male’ (or similar terms like ‘biological’ female or male),” Rolfe explained, “is not culturally competent verbiage for this community.” Ava was “a 13-year-old trans boy.” (Diane Ehrensaft, a pioneer of “gender-affirming care” for children, says that kids who identify as the opposite sex actually “hate, and I mean hate, the word trans.” They prefer to be referred to as just boys or girls, in accordance with how they identify.)

Rolfe’s e-mail did not persuade Pietzke, but by that point it didn’t matter. Rolfe had referred the case to a risk-management team at MultiCare. This came as relief for Pietzke, who thought having a third party entrusted with health-care quality assess Ava’s case would surely result in support for her position. But to her surprise, the risk-management team immediately sided with Rolfe and transferred Ava to another therapist—presumably one who would write the letter of support for hormones.

Pietzke finally got her answer. To be an “affirming” mental-health provider, according to everybody at MultiCare with authority over this area of care, meant setting aside any reservations about the potential for harm from hormonal interventions and approving even patients with stories as extreme as Ava’s for testosterone.

In a follow-up communication with Rolfe, Pietzke revealed another detail about Ava. The 13-year-old said that her classmates “call[ed] her retarded because I’m a furry—running on all fours, jumping, that sort of stuff.” Furries, explains one researcher sympathetic to the subculture, “are people who have an interest in anthropomorphism.” The subculture has been linked to sexual paraphilia, an association some of its members reject. Regardless, there seems to be an overlap between the furry and trans subcultures. Rolfe’s response to learning about Ava’s furry-like behavior at school was that this was “not relevant information to gender identity or gender dysphoria” and not a reason to deny her testosterone.

Not willing to abandon Ava, Pietzke decided to write a letter of support—for additional therapy, not hormones. On January 2, 2024, she sent the letter to four people: her supervisor, the new therapist assigned to Ava, Rolfe, and Kim Cummins, the certified professional in healthcare quality (CPHQ) and senior risk manager at MultiCare who approved Ava’s transfer. Pietzke explained in detail why hormones were inappropriate for Ava. She even cited the relevant sections in the World Professional Association for Transgender Health’s (WPATH) Standards of Care in its eighth revision (SOC-8) that support her position. In previous communications with Cummins and Rolfe, Pietzke was told that MultiCare uses SOC-8.

Experts in evidence-based medicine have criticized SOC-8 as untrustworthy, and WPATH’s more outspoken critics have designated SOC-8 a dangerous document. SOC-8, for instance, falsely claims that a systematic review of evidence for pediatric transition is “not possible.” It recognizes “eunuch” as a valid “gender identity,” including in children, characterized by a sincere desire to be castrated. It also recommends untraditional genital surgeries such as “penile-preserving vaginoplasty” (a procedure that constructs a pseudo-vagina underneath the penis) for males who identify as “non-binary.” Within days of SOC-8’s release, WPATH eliminated all age minimums for hormones and surgeries except phalloplasty, later explaining that it wanted to shield providers from legal liability. Several European countries have now broken with WPATH and are developing their own standards of care, based on systematic evidence reviews and a more traditional understanding of medical ethics.

Not so in the United States. Here, SOC-8 has come under criticism from “affirming” clinicians as being too conservative. In the months leading up to SOC-8’s release, gender clinicians criticized WPATH for excessive “gatekeeping.” “The adolescent chapter is the worst,” one trans-identified doctor told the New York Times. Another complained that SOC-8 authorizes a “comprehensive inquisition of [trans-identified adolescents’] gender.” The International Transgender Health Group argued that the adolescent chapter “undermines patient autonomy.” Christopher Lewis, the endocrinologist at whistleblower Jamie Reed’s clinic in St. Louis, privately confided in his colleague that he had “no idea how to meet what would be the most intensive interpretations of the SOC,” meaning that he found SOC-8’s already-weak safeguards too prohibitive.

As for Pietzke’s dispute with Multicare, SOC-8’s Statements 6.3 and 6.12 would appear to support her decision not to recommend Ava for hormones. Statement 6.3 instructs mental-health providers to conduct a “comprehensive biopsychosocial assessment” and to recognize that “[a] process of exploration over time” might result in the adolescent not wanting to go through with hormones. The statement emphasizes that “[t]here are no studies of the long-term outcomes of gender-related medical treatments for youth who have not undergone a comprehensive assessment” and recommends an “extended assessment process . . . for youth with more complex presentations (e.g., complicating mental health histories), co-occurring autism spectrum characteristics, and/or an absence of experienced childhood gender incongruence.”

Statement 6.12 is even more explicit. It says that adolescents should possess “the emotional and cognitive maturity” to give “informed consent” or “assent” if a legal guardian provides consent. Assent is “a somewhat parallel process in which the minor and the provider communicate about the intervention and the provider assesses the level of understanding and intention.” Adolescents need to understand that they may experience a “shift in gender identity” over time. They must be able “to reason thoughtfully” about treatment prospects, including permanent loss of fertility, or impaired fertility, and irreversible physical changes.

In the original Dutch study that SOC-8 considers the best available evidence for pediatric gender transition, active parental involvement was deemed necessary—not only for legal reasons but also because the parents were assumed to know the adolescent best and could provide clinicians with critical information about the success or failure of each stage of transition. But in this case, neither Rolfe nor Cummins seemed to think that it was a problem that the adult providing “informed consent” on Ava’s behalf was her mother’s ex-boyfriend.

Mental-health problems, neurocognitive issues, difficulty coming to terms with one’s homosexuality, and a history of trauma can produce symptoms or experiences similar to those of long-term gender incongruence—making differential diagnosis essential. Section “d” in Statement 6.12, for example, “elaborates on the importance of understanding the relationship that exists, if at all, between any co-occurring mental health or developmental concerns and the young person’s gender identity/gender diverse expression,” as mental health concerns “may interfere with diagnostic clarity” and “capacity to consent.” SOC-8 deems it “critical to differentiate gender incongruence from specific mental health presentations, such as obsessions and compulsions, special interests in autism, rigid thinking, broader identity problems, parent/child interaction difficulties, severe developmental anxieties (e.g., fear of growing up and pubertal changes unrelated to gender identity), trauma, or psychotic thoughts.” Further, “Neurodevelopmental differences, such as autistic features or autism spectrum disorder . . . may challenge the assessment and decision-making process; neurodivergent youth may require extra support, structure, psychoeducation, and time built into the assessment process.” Though comorbid mental-health concerns do not have to be “resolved completely,” according to Statement 6.12, they should be relatively well-managed before medical interventions are considered. “A provider’s key task is to assess the direction of the relationships that exist between any mental health challenges and the young person’s self-understanding of gender care needs and then prioritize accordingly.”

Recall that Rolfe asserted the opposite: the only conceivable cause of gender incongruence/dysphoria is “gender,” and other problems such as “trauma, autism, [or] other mental health conditions” are not relevant to diagnosis or treatment decisions. At minimum, SOC-8’s more cautious language would seem to support a delay in medical interventions for patients like Ava and a more extensive assessment period. This isn’t to stipulate that SOC-8 is a reasonable or evidence-based guideline—it is not— but that the approach taken by “affirming” providers like Rolfe is even more extreme.

Rolfe responded to Pietzke’s letter of support for more therapy by denying that any of her concerns about Ava’s mental health and past were “relevant information to gender identity or gender dysphoria.” Pietzke wrote back to Rolfe on January 4, citing in even greater detail the relevant passages in SOC-8 and parts of the Cass Interim Report (e.g., page 57) that discuss the various pathways into and out of gender dysphoria. Rolfe did not respond. A few days later, Pietzke quit MultiCare.

I reached out to Rolfe and Cummins for comment. Neither responded. I also contacted representatives of the American Academy of Pediatrics, WPATH, the American Academy of Child and Adolescent Psychiatry, the American Psychiatric Association, and the American Medical Association and asked each if they agreed with the following two statements from Rolfe’s e-mail:  “Trauma history is not a contraindication of [hormone replacement therapy]” in gender dysphoric adolescents; and “[t]here is not valid, evidenced based, peer reviewed research that would indicate that gender dysphoria arises from anything other than gender (including trauma, autism, other mental health conditions, etc.). At it’s [sic] core the diagnosis centers on an incongruence of gender identity and assigned gender at birth.” None of the organizations responded.

Two months after Pietzke’s exchange with Rolfe, the World Health Organization, which Rolfe also cited, released a statement clarifying that it would not issue guidelines on medical transition for minors, given that evidence for medical interventions in this age group was “limited and variable.”

I asked clinical psychologist Laura Edwards-Leeper what she thought of Rolfe’s e-mail exchanges with Pietzke. Edwards-Leeper is an Oregon-based therapist who chaired the WPATH child and adolescent committee ahead of the SOC-8 revision. She was also the founding psychologist of the nation’s first pediatric gender clinic in Boston.

“I continue to be astounded by the lack of appreciation among providers who serve gender dysphoric youth for the multiple pathways that can lead to gender dysphoria,” she told me. “This lack of awareness is particularly shocking given the shifts occurring in numerous European countries toward a more cautious approach. The clinical conceptualization provided by MultiCare’s gender-affirming care specialists and the lessons taught in the training given to Tamara and her coworkers are not only antiquated but potentially harmful for many of today’s gender distressed youth. Moreover, they suggest a gross misinterpretation of the current WPATH Standards of Care (version 8), which I helped develop.”

Photo: Nadzeya Haroshka/iStock/Getty Images Plus


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