Scott’s presentation came from a batch of nearly 500 videos of conferences held by WPATH that I recently obtained. It’s a motherlode of material on pediatric gender care that the secretive activist medical organization had long fought to keep from the public. The tapes, subpoenaed by the Alabama attorney general in response to a federal lawsuit, covered a pivotal period from 2021 to 2023, when pediatric gender medicine first began to face political backlash. In addition to egregious lapses in judgment on the part of WPATH, the videos are a case study in the excesses of peak woke, neatly preserved, as if in a time capsule. 

During a long winter of dyspepsia, I digested well more than 100 hours of the academic faithful checking their privilege and preaching about “centering lived experience.” And I can now report that there are few subcultures more slavishly faithful to the woke religion than WPATH was during the post-Racial Reckoning micro-era. 

According to sociologist Musa al-Gharbi’s landmark 2024 book, We Have Never Been Woke: The Cultural Contradictions of a New Elite, the term woke, in its original, early-20th-century definition, referred to “an awareness of social injustices and a commitment to rectifying them.” Today, it is typically used pejoratively for anything Left-coded that might “seem ridiculous,” as al-Gharbi observed. And not always unjustly: at its peak, the philosophy amounted to a form of egalitarian signaling by cultural elites that purported to serve the needs of the marginalized — mostly by hewing to politically correct positions on gender, sexuality, race and identity issues — but in fact mostly served their own needs for status and legitimacy. 

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I observed all these tendencies at the WPATH conferences, which were held virtually during Covid times, and then in hotel conference rooms in Montreal and Denver, and featured the titans of transgender medical care. One could only expect such discourse given the cast of characters. There were LGBTQ identities (and allies). There were overly educated cultural elites. There were activists. And there were guilty white people — overwhelmingly and blindingly white people — who sought to compensate for their inadequate melanization through promises to diversify WPATH and promote equity across the land.

These defenders of the marginalized were fluent in the academic-elite lingua franca of critical theory, intersectionality, and social justice, hewing to conformity at the expense of content, common sense, or even their own supposed mission to help gender-distressed children and adolescents. They stayed ahead of what Steven Pinker coined the “euphemism treadmill,” rattling off all the latest identity-politics jargon — deftly observing the imperative to shift from “transgender,” to “gender diverse,” to “gender expansive”; and from “Latino,” to “Latinx,” to “Latine.” They doled out trigger warnings for bread-and-butter medical subjects — to audiences of doctors and psychologists. 

In one session, which concerned the informed-consent model for providing gender surgeries, attendees were instructed to “please feel free to leave or take a break if need be. We want you to prioritize your own well-being above the content that we are sharing here.” 

They succumbed to concept creep, with one presenter defining trauma as “an experience or series of experiences that negatively affect someone’s interactions and experiences of moving through the world” — a definition so diffuse it could apply to anything from the Holocaust to a hangnail. And they undermined their own authority, responsibility, and legitimacy as care providers endowed with doctorates, as they conveyed that their young patients’ narratives were more important than diagnostic and scientific precision and the core principles of medical ethics.

Were there pronoun declarations? But of course. In fact, a WPATH conference is the rare setting where this performance might be useful. However, the vast majority of presenters, sometimes to their own professed chagrin, were not transgender. Most were straight women and gay men; the latter rarely admitted such a jejune and déclassé sexual identity, opting instead for obliquely declaring themselves “a member of the LGBTQ+ community.” 

The presenters didn’t stop with simply professing themselves a they/them. They routinely introduced themselves according to their sexual, racial, and class-based identities, making a point of self-flagellating should their oppression score prove subpar. One typical throat clearing was: “I’m a cisgender white woman who comes from a lot of privilege.” Another team declared: “We are white providers,” who, when caring for patients, took into consideration “the soup we all swim in, which is the dominant white Western ideas of what gender is, can be, should be.” Presenters displayed performative guilt and — with no sense of irony — apologized for their status as central players in a power structure that they were eagerly leveraging to promote the medicalization transgender identity in minors, even as they denounced that system as woefully damaged and damaging. 

Overall, the conference sessions placed a disquieting emphasis on correct-signaling over evidence-based medicine. If the presenters genuinely hoped to win over the public and other medical skeptics and establish gender-transition treatments and surgeries as a settled practice in pediatrics, one might have expected them to observe exacting caution and engage in scientific testing sufficiently rigorous to defend the ethics of providing irreversible, life-changing body alterations to highly distressed and impressionable minors. Alas, no.

Conference attendees were treated, for example, to a short sermon by Florence Ashley (they/them), a Canadian “transfeminine” legal scholar and author of Gender/Fucking: The Pleasures and Politics of Living in a Gendered Body. Ashley, a biological male who claims a loosely designated feminine identity, preached that erecting “gatekeeping” around gender-transition interventions for patients of all ages was “illegitimate by default.” 

There was also a session on experimental medical interventions for patients who identify as nonbinary. Dr. Walter Bouman, a British transgender-care specialist and WPATH leader, acknowledged working in the dark in this particular discipline. “We simply don’t have the evidence,” he admitted. And yet he and other care providers claimed it an imperative to provide mix-and-match sets of sex characteristics based on patients’ demands.

Such blind devotion to patients’ body-modification impulses extended even to minors and their “embodiment goals.” Dr. Johanna Olson-Kennedy, a top pediatric gender doctor practicing in California, confessed at the conference in 2023 that determining whether patients are “really trans” is “actually not the discussion I’m interested in participating in.” Instead, she wanted to talk about “giving the very best possible care to trans young people.” Nowhere in this astonishing confession was there room for determining whether a child’s gender confusion could  prove only temporary— and thus there was no consideration of whether the youth might later regret the medical intervention. 

Instead of caution we got hyperbolic warnings about white supremacy. Presenters such as policy wonk Kellan Baker and ACLU litigator Chase Strangio claimed, with no evidence, that objections to pediatric gender medicine, or to biological males participating in girls and women’s sports, were rooted in racist attitudes. Meanwhile, the conference sessions repeatedly called rueful attention to the fact that, despite everyone’s better efforts at recruitment, the organization’s leadership and its members were overwhelmingly white, as were their pediatric patients, as were youths participating in their studies. 

Such laments were paired with commitments to the equitable provision of medical interventions to nonwhite populations. White presenters ritually groveled over their racial or cispatriarchal supremacy. One, Dr. Carl Streed, a WPATH leader — a white gay man and primary-care physician at Boston Medical Center — heartily agreed to an observation that men of his persuasion controlled trans research and should voluntarily “step down” from leadership positions. 

These scenes highlight the intrinsically unstable nature of the woke belief system, which has always displayed contradiction and paradox. For example: race is a mere arbitrary social construct best dismissed and yet should be a source of monomania given that it is the architecture upon which all of society is built. Or this: given the overwhelmingly white makeup of WPATH and the field’s population of minor patients, perhaps pediatric gender medicine itself is fundamentally white. Where is the respect for marginalized cultures, when one of the chief professed goals is to impose what amounts to a glaringly white undertaking onto black and brown children?

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The only black trans woman I saw in all the WPATH videos I observed was Dr. Elle Lett, an activist-oriented statistician-epidemiologist (and insufferable gadfly on social media). Dr. Lett was still in training at the University of Pennsylvania when she gave a ramblingly woke plenary address to the 2021 conference. “Medicine,” she claimed, was “nested in the system of oppression,” and statistical methods “develop[ed] out of eugenics.” She called on attendees to “reject the notion of sample size and validity” in favor of messier science, provided it gave voice to the voiceless. The most mind-scrambling scenes came from sessions in which presenters preached the imperative to provide gender-transition treatment to Native Americans of all ages. 

I have no doubt that the WPATH conference presenters genuinely approach their medical mission with compassion. They routinely and emphatically expressed concern for their pediatric patient population, with apparent sincerity. But the quasi-religious zealotry I observed provides a weak foundation for a medical movement that seeks to care for a population of psychically unwell teenagers by subjecting them to drastic and permanent physical alterations. And it’s hardly possible to dispassionately weigh the risk versus benefits of these medical interventions when an unfalsifiable mode of new-age spirituality is pressing its finger on the scale. 

But a blindness to one’s own hypocrisy has always been the defining feature of the woke movement. So it’s no surprise that these medical radicals have proved incapable of self-correction, and that external political forces have stepped in to smash the precious temple they’ve built. 

Trepanning (drilling a hole in someone’s skull) has been conducted for millennia, with evidence of the oldest procedure dating back several thousand years. Archaeological finds of skulls with multiple holes in various states of repair indicate that at least some of our ancestors survived these treatments and came back for more. Opening a space to let the demons out of someone’s head makes sense, if you believe the pesky things have taken up residence and are running amok inside. At least this treatment was in the right anatomical ballpark, according to our current understanding of epilepsy as a neurological condition. Less than 130 years ago, surgery for epilepsy had “advanced” (or regressed) to the extent that the head was no longer the sole target of the surgeon’s scalpel.

They had branched out to recommend limb amputation. The rationale was straightforward: if someone’s arm keeps shaking, what more effective cure than to cut it off? Other surgical approaches to epilepsy in the 1890s included clitoridectomy and castration — both attempts to curb the immoral sexual appetites that were “well known” to cause epilepsy at the time. For the squeamish patients who wished to retain their sexual organs, alternative treatments included admonitions to avoid coffee, chocolate and amorous love songs. Late Victorian treatments for epilepsy were nothing if not eclectic.

Into the mid-20th century, people with epilepsy were once again the unwitting participants in a dark era of medical experimentation. In an enterprising spin-off, the radical surgical techniques developed in the Forties’ psychosurgery movement were trialled as treatments for epilepsy. All undergraduate psychology students (and fans of the film Memento) will be aware of Henry Molaison, better known by his initials. In October 1953, Mr Molaison underwent surgical excision of the right and left temporal lobes of his brain. In a short paper delivered six weeks after the surgery, his surgeon reported that the operation had resulted in no real changes, “with the exception of a very grave recent memory loss”; H.M. was unable to remember where his room was in the hospital, or how to find the toilet.

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H.M.’s profoundly disabling amnesia persisted for the next 55 years, until his death in 2008. He became the most famous neuropsychological case study in the history of the profession. But he was not the first person to undergo this procedure and suffer this devastating outcome. Scores of others were discovered in a retrospective review, triggered by Mr Molaison’s case. His memory loss could have been anticipated and prevented if the outcome of this procedure had been fully evaluated in his predecessors. More shocking still is that a similar fate was allowed to befall a number of other patients after his amnesia was discovered. Ignorance is one thing, inertia something entirely different.

The lessons from this sobering history are clear. When doctors fundamentally misunderstand the cause of a condition and treat the symptoms instead, and fail to properly monitor outcomes, and modify their practice in response to known adverse outcomes, our patients suffer — often greatly and for the rest of their lives — if indeed they survive. These fundamental errors underpin the depressingly regular scandals that punctuate the history of medicine. (The stakes are particularly high if surgery is involved.)

It is naïve to think that all these scandals are in the past. Our descendants will look back at some aspects of our current medical practice and wonder that we could have been so stupid. They will shudder at how barbaric and crude some of our current treatments are. So where might the next medical scandal be brewing?

The increasing visibility of detransitioners suggests it may lie in wait in gender-affirming medicine. Many detransitioners are young women who underwent treatment for psychological distress that has left them with irreversible, life-long changes to their bodies: a deep voice, a beard, and compromised sexual function. Some have had their breasts surgically removed; some may be infertile. Others are young men who have been castrated.

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This is not an argument about the pros and cons of these treatments for trans-identified young people. Nor is it an argument about the percentage of people who may “regret” undergoing these procedures. The existence of just one detransitioner suggests that an individual was not offered the correct treatment for their condition by the doctors charged with their care. It is a clear case where the medical profession caused harm. We are ethically bound to learn, and widely disseminate, the lessons from these cases.

For many detransitioners, the cause of their distress as a teenager was misattributed by their clinicians to the notion that they had been born in the wrong body, and that they would be helped by the surgical creation of the “correct” body. Regardless of the validity of this treatment for some — on which I make no comment — this assumption was incorrect in the case of many detransitioners. Once these fundamental errors of misattribution had been made by the treating clinicians (who in the case of GIDS were primarily psychologists, and not medically qualified), surgeons and endocrinologists embarked on a procedure akin to that of limb amputation for epileptic seizures. The detransitioners’ discomfort with their body was a symptom of psychological distress, not a cause, but their medical team prescribed treatments with an irreversible impact and surgically removed healthy tissue in an effort to cure their symptoms.

In most other fields of surgery, this would be classified as a “never event”, and an exhaustive investigation would be launched. But in the case of many detransitioners, their treating medical team has failed their patient at every stage. They have fundamentally misunderstood the nature of the condition the patient has presented with and have treated the symptom rather than the cause. The astonishing failure of the Tavistock & Portman NHS trust to monitor even primary outcomes were laid bare in the original trial of Bell vs Tavistock, with further shocking details subsequently presented in Hannah Barnes forensic account of the collapse of the service. This failure means there is no opportunity to modify practice in response. It is unsurprising that the results have been catastrophic for some.

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However, in the case of detransitioners, there is an additional, darker layer to this cascade of medical errors. The patients themselves are being held responsible, by the very doctors who made them. The term “post-treatment regret” appears to abrogate any responsibility on behalf of the treating clinicians for these outcomes. Some argue that there is some degree of regret associated with every medical procedure. However, there is a fundamental difference between patients who are unhappy with the outcome of elective treatments recommended for their condition, and those who have been misdiagnosed, and have had healthy tissue surgically removed as a result. Many detransitioners were given the wrong treatment for their condition. These people are not experiencing post-treatment regret, they are responding appropriately to the consequences of a grave medical failure.

Advocates of gender-affirming care argue that “no one can know whether post-treatment regret will occur; therefore what matters ethically is whether an individual has a good enough reason for wanting treatment”. This is a remarkable position to take. Surely what matters ethically is that the medical profession offers appropriate, evidence-based treatment to patients who will benefit from them. Others argue that young trans people have “the right to be wrong”. They do indeed; doctors, less so, particularly when they are wielding a scalpel. Just as trans youth deserve access to the very best in evidence-based medicine, so doctors have a fundamental duty not to offer harmful treatments to young people who will not benefit from them. It is not good enough to shrug and say, “no one knows whether this will occur”. We know that poor outcomes do occur, and are duty-bound to find out as much as we can about these in order to predict and prevent them.

Since 2014, there has been a phenomenal increase in young women referred to specialist services for gender dysphoria. There is, therefore, a greater number of people who are at potential risk of receiving inappropriate treatments. To respond by creating a “fast-track” to medical transition is to ignore everything history has to teach us. Meticulous assessment of a young person’s symptoms is not transphobic, nor does it invalidate anyone’s identity. It is good medicine, and ensures that the right treatment is given to the right patient.

No branch of medicine can be exempt from rigour. Exceptionalism lies at the heart of many medical scandals. That way catastrophe lies and, as ever, it will be our patients who suffer. This is not hypothetical: detransitioners stand before us as living, breathing examples of people who have been harmed. To change nothing as the result of their experience — or, even worse, to make changes that mean similar errors could potentially harm even more people — is immoral. Upholding scientific principles is the least we can do to protect our current patients and honour the thousands who have been failed by the medical profession in the past. The history of surgery can teach us that much. It is our responsibility to take note.