Saw your lovely podcast with Benjamin Boyce. And I just wanted to message you a couple snippets of information that might be helpful as you construct your book! (No idea if you will see this since I am just an Anonymous account on Twitter, which doesn’t tweet or have anyone follow me.) But as a current medical student interested in this stuff, I just wanted to shoot you a comment with some more bits of medical context that you might consider when constructing your book, or maybe just find interesting, because you clearly love learning about endocrinology, and the current dynamics, governing transgender medicine.
1 small correction: I think you called Lupron a GnRH antagonist. (blocker) As in it simply blocks the release of GnRH. But interestingly Lupron is actually an agonist - as in it stimulates the GnRH receptors. And then this overstimulation basically shuts the production of GnRH down. (bunch of hypothalamic hormones are regulated by and also secrete in a pulsatile pattern. Frequency of pulse determines release or not.) ….. so lupron = GnRH AGONIST that weirdly SUPPRESSES GnRH release.
## (GnRH ANTAGonists are actually some thing that is a bit NEWER than lupron - **Linzagolix, ganirelix, cetrorelix-** and usually used for breast / prostate cancer. May eventually become the standard of care for those malignancies. But Tbd.)
Also yes messing with GnRH treats both precocious puberty and breast cancer, but you should also know it treats prostate cancer also which is pretty cool. Because prostate cancer basically grows off more testosterone. And so if you shut down that FSH and LH you shut down testosterone production too. → stop stimulating prostate tissue proliferation.
(So basically I’m just trying to tell you that Lupron is a GNRH AGONIST not ANTAGonist… which is basically the same thing, but different LOL. - and still good to get those little details right if you want physicians to read your work and take it seriously from a technical perspective!)
If I said "antagonist" instead of "agonist", then I misspoke, I know that puberty blockers are GnRH agonists and that they work because constant agonism leads to rapid downregulation of GnRH receptors. Thanks for checking to make sure the facts are right though :-)
Also as far as the lower IQ point - I have seen those studies. But probably a good thing to acknowledge is the fact that the kids if they test this on we’re not just a random group of kids. They were specifically a group of kids with precocious puberty as you mentioned. So it is a bit difficult to SEPERATE where that IQ drop is coming from. - Is it a result primarily of their pre-existing endocrine abnormality/dysfunction. Just another symptom of their endocrine underlying disorder that they transiently take Lupron for? Or is it actually the effect of administering the Lupron. My bet is on that it is probably a combination of both. But not really worked out at this point. Underlying condition that these kids are being treated for is still giant confounder when trying to untangle the cause of the small IQ drop. Unclear, if this is an effect that you would only see in this population of kiddos undergoing precocious puberty, or a more generalized side effect that you could reasonably expect in some proportion of general pediatric population, who might seek puberty blocking for gender affirming care. So just probably good to make it clear that you know all sides of the issue! Correlation not necessarily causation always. currently unclear, but of course plausible mechanism to suspect that it might possibly be a result of the drug itself. Etc.
Also estrogen does have to deal with bone growth. For postmenopausal women. When women stop making estrogen. That is when you see things like old ladies falling and shattering their entire pelvis. Which is because estrogen actually makes your bones stronger. And estrogen deficiency is going to result in osteoporosis. So one reason that a woman may choose to jump on estrogen replacement therapy after menopause in addition to getting rid of hot flashes and other nasty things like that is because they might have scored low on a bone density scan and estrogen can help prevent worsening osteoporosis.
Relevant to trans people as I’m sure you know, with some reports of very young (FTM mostly I think) kids getting extreme osteoporosis because they are  taking Lupron, shutting down that GnRH axis, and then not getting the estrogen that they need to make their bones strong
##  and interestingly on the other side of the coin not related to postmenopausal women. Estrogen also plays a role in YOUNG MEN. Specifically estrogen helps close the epiphyseal growth plates. Like you said. So interestingly people with an aromatase deficiency end up being taller because those growth plates close later /after they were supposed to. interesting fact related to how you were talking about these hormones, regulating literally every tissue in your body in a different way.
Aromatase is the way that XY people get most of their estrogen. It is an enzyme in fat cells that basically can convert testosterone/androgen into a form of estrogen. ⋯⋯ also a reason why some postmenopausal women end up getting estrogen receptor positive breast cancer, which you would think probably wouldn’t happen much because the whole point of menopause is that you stop estrogen production. But specifically a concern in women who have a lot of excess fat tissue/obese women during menopause - their theca cells are still going to be generating some androgens(T) at ovaries. (normal function) Which get converted peripherally in fat tissue via aromatase into estrogen. And so that is why you often see postmenopausal obese women get breast cancer. - Basically because excess fat tissue is generating that extra estrogen from that normal baseline androgen synth. - Specifically this tends to happen in people with the BRCA1 gene, which is highest in the Ashkenazi Jewish population (me!) which is why when I hit menopause, because I am a baby and plan to take hormone replacement therapy because I do not want to deal with hot flashes and nausea, But since I am of Ashkenazi Jewish ethnicity, that means that I am probably going to have to be extra aggressive on those mammograms because I don’t want to be increasing my propensity to develop breast cancer.
 also as I’m sure you know it is possible for some men to get breast cancer. And usually the men that do end up getting breast cancer have that BRCA1 mutation. So I do really wonder if in transgender women who go on estrogen therapy and have that underlying BRCA1 mutation - if they should also be super aggressive with the mammograms and screening just to make sure that no cancer problems pop up. + relative risk compaired to cis women w and w/o the mutation. Very much not some thing that is really discussed or acknowledged at all as a possible concern to mitigate.
## Instead, it seems like it is usually turned into what I have heard to referred as “transgender broken arm syndrome” where physicians are encouraged NOT to consider cross sex hormones as a cause, or even contributing factor to a patient, presenting, with a complaint, unrelated to their gender/genitals. (Yes I realize this is terribly ironic that it is called "broken arm" syndrome, given the very real/widely acknowledged issues with low bone density that can come about as a result of some of these trans-related drugs. It seems to me that if I was trying to do the very best for my patient, I would definitely at least consider any drugs that they might come with this known side effect profile. but we are actively encouraged NOT to do that, as it is a sign of transphobia/hostility…… If I was a transgender patient, I think I would want my doctor to consider all aspects of my medical situation in the ER… but I guess since i am not, whatever lol.)
Also, given the widely acknowledge, hematological consequences of birth control, – more estrogen means you make more clotting factors, thus, raising your risk of things like DVTs/strokes in women taking oral contraceptives. (Plus rarely can get a variety of weird liver, tumors basically made of blood, which regress when the woman stops taking birth control. But can cause problems if she doesn't. ) I do wonder about those things for transgender women on estrogen therapy. And really hope that some good studies are done to look at how much of an elevated risk that might present. Just so that people can have all the information when deciding their path forward. Would be super easy to compare, thrombotic events in a big group of transgender women taking estrogen to an analogous population of cis gender man. (I really don't know the answer because testosterone is well known to worsen lipid profiles. Increased LDL plus lower HDL. Which is why they think that men suffer, severe/deadly cardiovascular events at a younger age and more often. Also well known consequence of anabolic steroids, a.k.a. testosterone… which can cause some pretty serious, cardiovascular issues. Even in non-bodybuilders like my dad who is a 60 year old. Random dude on a super low dose of testosterone - only thing that he has found alleviates fatigue/general feelings of ickyness - but now has a extremely concerning lipid profile, which caused his doctor to call him in alarm because he has a pretty big risk of having a heart attack in the next few years, if nothing is done)
## so I really do wonder about how the increased clotting factors from estrogen therapy, balance out vs. eliminating dyslipidemic effects of testosterone in genetically XY people. Does this cause some net effect of either increased, decreased, or no change it all in cardiovascular events? I feel like whatever the answer, this is information that patients considering hormone replacement would probably like to know one way or the other. After all, there are a lot of mitigation strategies on the market that would be very easy to prescribe if there was some elevated risk. Similar to the way that we prescribe clopidogrel after Inserting a stent into somebody’s heart- to fight against the prothrombotic effect of said stent. I just really don't like the direction this branch of medicine seems to be going in, where we are forced to look through rose tinted glasses, and pretend like this is the first medication in human history that doesn't have any side effects to consider or even keep our eyes peeled for as physicians.
Had a lecture from some endocrinologist who specializes in treating trans people specifically kids. And he was very cavalier about it any possible side effects. Basically had like one slide saying oh yeah maybe there are some cardiovascular issues but I kind of doubt it but I guess we can have more studies or something maybe. Which is super concerning to me drs should always always always be trying to provide an opportunity for the patients to have the most informed consent possible. If there is some thing that could go wrong when giving my patient a powerful drug, I really want them to be fully informed about that possibility and be able to make the decision if they want to move forward with pharmacotherapy knowing full well all the information. unmitigated optimism about new pharmacotherapy = danger.
I think we saw what an absolute debacle that was in the opioid epidemic. All these doctors became evangelists for the magic of OxyContin and insisted edit that there was basically no side effects and everybody could take it carefree with “totaly no adverse side effects to consider”. “We are going to eliminate pain from America“ or whatever. But there are always unhappy side effects to any drug that you choose to put in your body. And it’s a matter of the patient understanding that risk, weighing the cost and benefits for their own personal situation/ preferences and choosing for themselves. Medicine cannot operate in happy go lucky La La Land where are you go to the doctor with a concern and they assure you that they have the absolute silver bullet that will solve all your problems without creating any others that you might even POSSIBLY consider (that sounds like a snake oil salesman to me) There are no perfect solutions, only trade-offs.
## Also, somewhat concerning to hear so many doctors, including the pediatric endocrinologist that lectured us about gender, affirming hormone therapy, basically say that all of the “checks” that people have to go through in order to be approved for transgender therapy are simply bigoted roadblocks, which we are currently in the process of fighting to remove and tear down. I agree with you that adults should have total freedom to choose to do anything with their own body that they damn well please. So OK, maybe all of these little checks and approval steps for adults could be removed, simply putting the responsibility and choice on the individual. - But tearing down those double checks for a specifically pediatric population, who might not really have the cognitive capacity to understand what it is that they are consenting to, is kind of crazy and reckless. But like you say, there are obviously a lot of kids, who are those surefire cases, and can benefit from starting transition in childhood. The trouble is that it’s difficult to identify which kiddos. This is going to be a good choice for, and who it is going to end up, causing a lot of regret for. So I think those processes of trying to figure out if a child falls on one side or the other make quite a lot of sense in such a new area of medicine with a lot of unknowns and uncertainties. As a former child, I can say that kids are f-ing stupid, and just because they say they want to some thing in the moment, doesn’t necessarily mean that that is going to be the best choice for them long-term, or that there isn’t something else going on in their lives that might be causing them distress, which won't necessarily be solved by an irreversible medical procedure. We as a society generally, accept this principle about children’s limited decision making capacity. But for some reason in this area, no dice.
 I used to want to be a plastic surgeon who would do gender reassignment/affirmation surgeries, because I thought that it was so beautiful to have the opportunity to take somebody who felt uncomfortable with their body all their life and give them the opportunity to finally look in the mirror and smile because they were happy with what they saw. But now with the changing rule of practices and it basically being illegal for a physician to provide “non-affirming care” - I would never be allowed to push back and say the same thing that other types of surgeons say often, specifically that “hey maybe we should consider some less invasive options and see if we can find a solution, or think about these things very deeply and make sure that this is REALLY what before you take the plunge and go under the knife. (Standard for women considering breast augmentation, hysterectomy, etc.) But that routine cautiousness is not allowed in the medical field of gender affirmation anymore. So as a result that makes me want to run as far in the opposite direction as I possibly can. - I think I will go into trauma surgery because that is a situation when someone comes to you in the worst moment of their life and basically the only choice that you could possibly make is to do everything that you can to save them under the knife. I am comfortable with that and all the pressure that entails. I am not comfortable concealing the shades of grey/reality of trade offs from my patients, to suit some shortsighted ideology. Which I do understand has come about because there has been such an aggressive push from conservatives in the opposite direction. But both sides of this extreme are wrong. There is a reason why it is called the art of medicine. Because the careful measured balanced approach is different for every patient and is always the right answer when you are trying to figure out what is going to be the best option for someone in a non-acute life threatening situation . (and even then, a balanced approach is still often important. Iatrogenic harm always possible and something to take account of as physicians who have people‘s lives in our hands. Just a lot more rapid and with less /no patient input if they are lying there in critical condition in front of you)
Anyway, just really appreciated your thoughts. And appreciate your autisticly objective look at an emotionally charged situation lol.  I deff relate as somebody who is probably somewhere on the spectrum, and is often very confused about how very intelligent people somehow let their feelings get so tied up in their assessment of objective reality. I think this seems to be the central pathology plaguing our society right now. And it’s a problem in many other areas of medicine which you may or may not know about or be interested in. It just breaks my heart to see so many posts going around on Reddit of trans youth who got the gender affirmation surgery and are now struggling with the horror that they didn’t fully understand what they were consenting to. I DK if you have seen that devastating post from a mom writing about her trans daughter who got a vaginoplasty using a portion of her colon. (Which they specifically had to do because she was on puberty blockers and her penis did not grow to an adequate size to be able to use it to construct a vaginal canal.) And now this young lady is dealing with a rather fecal smelling vagina, dating problems and psychological distress because she just doesn’t know what to do about her body. And then her mom is sitting there on some Internet forumn saying that she followed the advice of the medical experts to a T and did everything right from puberty blockers → hormones → surgery. and she just doesn’t understand how she could have possibly followed all the right steps just to end up with her daughter being so profoundly unhappy and in actually more emotional distress than when she started. I don't know what to say, other than the way that we go about these things / discuss them honestly, with the patients who are considering them seems to be only way forward from my perspective.
so in conclusion… i guess, I just wrote out all my thoughts after listening to your chat, because sometimes that helps you crystallize your thinking.
love how you simply sum up the mess as the fact that there are actually two types of MTF transgender people, (AGP v. “homo”sexual/ standard progressive idea of trans womanhood) and the way that clinicians go about understanding these two groups as one entity is leaving them blind → not able to provide or understand the best care for their patients. I think that that is very interesting and I have never heard someone state it that way. I also laughed out loud when you mentioned the fact that for conservatives who are uncomfortable with transgender people existing at all, it is bizarre that they are pushing back so strongly against this group of people essentially sterilizing themselves out of existence. When I see someone able to identify and acknowledge the bizarre/counterintuitive and messy irony of human dynamics, I think that’s usually a tell that they have a pretty solid un-clouded grasp on what is actually going on.  I dictated most of this via talk to text on my computer, so might be a couple weird errors if you end up reading this. But anyway, end of my weird probably pointless rant into the void lol.
"So What If Gender is a Social Construct?":
https://open.substack.com/pub/johncarpenter/p/the-transgender-bait-and-switch-b0b?r=yky21&utm_campaign=post&utm_medium=web
Saw your lovely podcast with Benjamin Boyce. And I just wanted to message you a couple snippets of information that might be helpful as you construct your book! (No idea if you will see this since I am just an Anonymous account on Twitter, which doesn’t tweet or have anyone follow me.) But as a current medical student interested in this stuff, I just wanted to shoot you a comment with some more bits of medical context that you might consider when constructing your book, or maybe just find interesting, because you clearly love learning about endocrinology, and the current dynamics, governing transgender medicine.
1 small correction: I think you called Lupron a GnRH antagonist. (blocker) As in it simply blocks the release of GnRH. But interestingly Lupron is actually an agonist - as in it stimulates the GnRH receptors. And then this overstimulation basically shuts the production of GnRH down. (bunch of hypothalamic hormones are regulated by and also secrete in a pulsatile pattern. Frequency of pulse determines release or not.) ….. so lupron = GnRH AGONIST that weirdly SUPPRESSES GnRH release.
## (GnRH ANTAGonists are actually some thing that is a bit NEWER than lupron - **Linzagolix, ganirelix, cetrorelix-** and usually used for breast / prostate cancer. May eventually become the standard of care for those malignancies. But Tbd.)
Also yes messing with GnRH treats both precocious puberty and breast cancer, but you should also know it treats prostate cancer also which is pretty cool. Because prostate cancer basically grows off more testosterone. And so if you shut down that FSH and LH you shut down testosterone production too. → stop stimulating prostate tissue proliferation.
(So basically I’m just trying to tell you that Lupron is a GNRH AGONIST not ANTAGonist… which is basically the same thing, but different LOL. - and still good to get those little details right if you want physicians to read your work and take it seriously from a technical perspective!)
If I said "antagonist" instead of "agonist", then I misspoke, I know that puberty blockers are GnRH agonists and that they work because constant agonism leads to rapid downregulation of GnRH receptors. Thanks for checking to make sure the facts are right though :-)
Also as far as the lower IQ point - I have seen those studies. But probably a good thing to acknowledge is the fact that the kids if they test this on we’re not just a random group of kids. They were specifically a group of kids with precocious puberty as you mentioned. So it is a bit difficult to SEPERATE where that IQ drop is coming from. - Is it a result primarily of their pre-existing endocrine abnormality/dysfunction. Just another symptom of their endocrine underlying disorder that they transiently take Lupron for? Or is it actually the effect of administering the Lupron. My bet is on that it is probably a combination of both. But not really worked out at this point. Underlying condition that these kids are being treated for is still giant confounder when trying to untangle the cause of the small IQ drop. Unclear, if this is an effect that you would only see in this population of kiddos undergoing precocious puberty, or a more generalized side effect that you could reasonably expect in some proportion of general pediatric population, who might seek puberty blocking for gender affirming care. So just probably good to make it clear that you know all sides of the issue! Correlation not necessarily causation always. currently unclear, but of course plausible mechanism to suspect that it might possibly be a result of the drug itself. Etc.
Also estrogen does have to deal with bone growth. For postmenopausal women. When women stop making estrogen. That is when you see things like old ladies falling and shattering their entire pelvis. Which is because estrogen actually makes your bones stronger. And estrogen deficiency is going to result in osteoporosis. So one reason that a woman may choose to jump on estrogen replacement therapy after menopause in addition to getting rid of hot flashes and other nasty things like that is because they might have scored low on a bone density scan and estrogen can help prevent worsening osteoporosis.
Relevant to trans people as I’m sure you know, with some reports of very young (FTM mostly I think) kids getting extreme osteoporosis because they are  taking Lupron, shutting down that GnRH axis, and then not getting the estrogen that they need to make their bones strong
##  and interestingly on the other side of the coin not related to postmenopausal women. Estrogen also plays a role in YOUNG MEN. Specifically estrogen helps close the epiphyseal growth plates. Like you said. So interestingly people with an aromatase deficiency end up being taller because those growth plates close later /after they were supposed to. interesting fact related to how you were talking about these hormones, regulating literally every tissue in your body in a different way.
Aromatase is the way that XY people get most of their estrogen. It is an enzyme in fat cells that basically can convert testosterone/androgen into a form of estrogen. ⋯⋯ also a reason why some postmenopausal women end up getting estrogen receptor positive breast cancer, which you would think probably wouldn’t happen much because the whole point of menopause is that you stop estrogen production. But specifically a concern in women who have a lot of excess fat tissue/obese women during menopause - their theca cells are still going to be generating some androgens(T) at ovaries. (normal function) Which get converted peripherally in fat tissue via aromatase into estrogen. And so that is why you often see postmenopausal obese women get breast cancer. - Basically because excess fat tissue is generating that extra estrogen from that normal baseline androgen synth. - Specifically this tends to happen in people with the BRCA1 gene, which is highest in the Ashkenazi Jewish population (me!) which is why when I hit menopause, because I am a baby and plan to take hormone replacement therapy because I do not want to deal with hot flashes and nausea, But since I am of Ashkenazi Jewish ethnicity, that means that I am probably going to have to be extra aggressive on those mammograms because I don’t want to be increasing my propensity to develop breast cancer.
 also as I’m sure you know it is possible for some men to get breast cancer. And usually the men that do end up getting breast cancer have that BRCA1 mutation. So I do really wonder if in transgender women who go on estrogen therapy and have that underlying BRCA1 mutation - if they should also be super aggressive with the mammograms and screening just to make sure that no cancer problems pop up. + relative risk compaired to cis women w and w/o the mutation. Very much not some thing that is really discussed or acknowledged at all as a possible concern to mitigate.
## Instead, it seems like it is usually turned into what I have heard to referred as “transgender broken arm syndrome” where physicians are encouraged NOT to consider cross sex hormones as a cause, or even contributing factor to a patient, presenting, with a complaint, unrelated to their gender/genitals. (Yes I realize this is terribly ironic that it is called "broken arm" syndrome, given the very real/widely acknowledged issues with low bone density that can come about as a result of some of these trans-related drugs. It seems to me that if I was trying to do the very best for my patient, I would definitely at least consider any drugs that they might come with this known side effect profile. but we are actively encouraged NOT to do that, as it is a sign of transphobia/hostility…… If I was a transgender patient, I think I would want my doctor to consider all aspects of my medical situation in the ER… but I guess since i am not, whatever lol.)
Also, given the widely acknowledge, hematological consequences of birth control, – more estrogen means you make more clotting factors, thus, raising your risk of things like DVTs/strokes in women taking oral contraceptives. (Plus rarely can get a variety of weird liver, tumors basically made of blood, which regress when the woman stops taking birth control. But can cause problems if she doesn't. ) I do wonder about those things for transgender women on estrogen therapy. And really hope that some good studies are done to look at how much of an elevated risk that might present. Just so that people can have all the information when deciding their path forward. Would be super easy to compare, thrombotic events in a big group of transgender women taking estrogen to an analogous population of cis gender man. (I really don't know the answer because testosterone is well known to worsen lipid profiles. Increased LDL plus lower HDL. Which is why they think that men suffer, severe/deadly cardiovascular events at a younger age and more often. Also well known consequence of anabolic steroids, a.k.a. testosterone… which can cause some pretty serious, cardiovascular issues. Even in non-bodybuilders like my dad who is a 60 year old. Random dude on a super low dose of testosterone - only thing that he has found alleviates fatigue/general feelings of ickyness - but now has a extremely concerning lipid profile, which caused his doctor to call him in alarm because he has a pretty big risk of having a heart attack in the next few years, if nothing is done)
## so I really do wonder about how the increased clotting factors from estrogen therapy, balance out vs. eliminating dyslipidemic effects of testosterone in genetically XY people. Does this cause some net effect of either increased, decreased, or no change it all in cardiovascular events? I feel like whatever the answer, this is information that patients considering hormone replacement would probably like to know one way or the other. After all, there are a lot of mitigation strategies on the market that would be very easy to prescribe if there was some elevated risk. Similar to the way that we prescribe clopidogrel after Inserting a stent into somebody’s heart- to fight against the prothrombotic effect of said stent. I just really don't like the direction this branch of medicine seems to be going in, where we are forced to look through rose tinted glasses, and pretend like this is the first medication in human history that doesn't have any side effects to consider or even keep our eyes peeled for as physicians.
Had a lecture from some endocrinologist who specializes in treating trans people specifically kids. And he was very cavalier about it any possible side effects. Basically had like one slide saying oh yeah maybe there are some cardiovascular issues but I kind of doubt it but I guess we can have more studies or something maybe. Which is super concerning to me drs should always always always be trying to provide an opportunity for the patients to have the most informed consent possible. If there is some thing that could go wrong when giving my patient a powerful drug, I really want them to be fully informed about that possibility and be able to make the decision if they want to move forward with pharmacotherapy knowing full well all the information. unmitigated optimism about new pharmacotherapy = danger.
I think we saw what an absolute debacle that was in the opioid epidemic. All these doctors became evangelists for the magic of OxyContin and insisted edit that there was basically no side effects and everybody could take it carefree with “totaly no adverse side effects to consider”. “We are going to eliminate pain from America“ or whatever. But there are always unhappy side effects to any drug that you choose to put in your body. And it’s a matter of the patient understanding that risk, weighing the cost and benefits for their own personal situation/ preferences and choosing for themselves. Medicine cannot operate in happy go lucky La La Land where are you go to the doctor with a concern and they assure you that they have the absolute silver bullet that will solve all your problems without creating any others that you might even POSSIBLY consider (that sounds like a snake oil salesman to me) There are no perfect solutions, only trade-offs.
## Also, somewhat concerning to hear so many doctors, including the pediatric endocrinologist that lectured us about gender, affirming hormone therapy, basically say that all of the “checks” that people have to go through in order to be approved for transgender therapy are simply bigoted roadblocks, which we are currently in the process of fighting to remove and tear down. I agree with you that adults should have total freedom to choose to do anything with their own body that they damn well please. So OK, maybe all of these little checks and approval steps for adults could be removed, simply putting the responsibility and choice on the individual. - But tearing down those double checks for a specifically pediatric population, who might not really have the cognitive capacity to understand what it is that they are consenting to, is kind of crazy and reckless. But like you say, there are obviously a lot of kids, who are those surefire cases, and can benefit from starting transition in childhood. The trouble is that it’s difficult to identify which kiddos. This is going to be a good choice for, and who it is going to end up, causing a lot of regret for. So I think those processes of trying to figure out if a child falls on one side or the other make quite a lot of sense in such a new area of medicine with a lot of unknowns and uncertainties. As a former child, I can say that kids are f-ing stupid, and just because they say they want to some thing in the moment, doesn’t necessarily mean that that is going to be the best choice for them long-term, or that there isn’t something else going on in their lives that might be causing them distress, which won't necessarily be solved by an irreversible medical procedure. We as a society generally, accept this principle about children’s limited decision making capacity. But for some reason in this area, no dice.
 I used to want to be a plastic surgeon who would do gender reassignment/affirmation surgeries, because I thought that it was so beautiful to have the opportunity to take somebody who felt uncomfortable with their body all their life and give them the opportunity to finally look in the mirror and smile because they were happy with what they saw. But now with the changing rule of practices and it basically being illegal for a physician to provide “non-affirming care” - I would never be allowed to push back and say the same thing that other types of surgeons say often, specifically that “hey maybe we should consider some less invasive options and see if we can find a solution, or think about these things very deeply and make sure that this is REALLY what before you take the plunge and go under the knife. (Standard for women considering breast augmentation, hysterectomy, etc.) But that routine cautiousness is not allowed in the medical field of gender affirmation anymore. So as a result that makes me want to run as far in the opposite direction as I possibly can. - I think I will go into trauma surgery because that is a situation when someone comes to you in the worst moment of their life and basically the only choice that you could possibly make is to do everything that you can to save them under the knife. I am comfortable with that and all the pressure that entails. I am not comfortable concealing the shades of grey/reality of trade offs from my patients, to suit some shortsighted ideology. Which I do understand has come about because there has been such an aggressive push from conservatives in the opposite direction. But both sides of this extreme are wrong. There is a reason why it is called the art of medicine. Because the careful measured balanced approach is different for every patient and is always the right answer when you are trying to figure out what is going to be the best option for someone in a non-acute life threatening situation . (and even then, a balanced approach is still often important. Iatrogenic harm always possible and something to take account of as physicians who have people‘s lives in our hands. Just a lot more rapid and with less /no patient input if they are lying there in critical condition in front of you)
Anyway, just really appreciated your thoughts. And appreciate your autisticly objective look at an emotionally charged situation lol.  I deff relate as somebody who is probably somewhere on the spectrum, and is often very confused about how very intelligent people somehow let their feelings get so tied up in their assessment of objective reality. I think this seems to be the central pathology plaguing our society right now. And it’s a problem in many other areas of medicine which you may or may not know about or be interested in. It just breaks my heart to see so many posts going around on Reddit of trans youth who got the gender affirmation surgery and are now struggling with the horror that they didn’t fully understand what they were consenting to. I DK if you have seen that devastating post from a mom writing about her trans daughter who got a vaginoplasty using a portion of her colon. (Which they specifically had to do because she was on puberty blockers and her penis did not grow to an adequate size to be able to use it to construct a vaginal canal.) And now this young lady is dealing with a rather fecal smelling vagina, dating problems and psychological distress because she just doesn’t know what to do about her body. And then her mom is sitting there on some Internet forumn saying that she followed the advice of the medical experts to a T and did everything right from puberty blockers → hormones → surgery. and she just doesn’t understand how she could have possibly followed all the right steps just to end up with her daughter being so profoundly unhappy and in actually more emotional distress than when she started. I don't know what to say, other than the way that we go about these things / discuss them honestly, with the patients who are considering them seems to be only way forward from my perspective.
so in conclusion… i guess, I just wrote out all my thoughts after listening to your chat, because sometimes that helps you crystallize your thinking.
love how you simply sum up the mess as the fact that there are actually two types of MTF transgender people, (AGP v. “homo”sexual/ standard progressive idea of trans womanhood) and the way that clinicians go about understanding these two groups as one entity is leaving them blind → not able to provide or understand the best care for their patients. I think that that is very interesting and I have never heard someone state it that way. I also laughed out loud when you mentioned the fact that for conservatives who are uncomfortable with transgender people existing at all, it is bizarre that they are pushing back so strongly against this group of people essentially sterilizing themselves out of existence. When I see someone able to identify and acknowledge the bizarre/counterintuitive and messy irony of human dynamics, I think that’s usually a tell that they have a pretty solid un-clouded grasp on what is actually going on.  I dictated most of this via talk to text on my computer, so might be a couple weird errors if you end up reading this. But anyway, end of my weird probably pointless rant into the void lol.