Before sharing this piece I want to clearly state my perspective on a few key issues:
- Adults who chose to medically transition deserve the best care medicine can afford them. Well-researched interventions with thorough long-term follow-up and robust informed consent are necessary.
- Advocates for ethical care of transgender and gender dysphoric patients such as Buck Angel, Scott Newgent, GCCAN, and UK Tavistock whistle-blowers like Marcus Evans and Dr. David Bell are key players in creating greater accountability for gender clinics, doctors, and surgeons. However, the regulation of largely experimental procedures shouldn’t be the responsibility of the patient or the practicing clinician through litigation and whistle-blowing, respectively.
- Drugs and surgeries should be well researched before being publicly touted as “cures” for children’s gender dysphoria.
- In writing this, I do not imply that the provision of transgender medical care should be stopped or completely discarded. Instead, this piece serves as a warning about medical hubris, media sensationalism, and overselling experimental medicine as a cure for a condition with a weak theoretical basis that is likely spread through social contagion.
- This piece is about the quick adoption of a radical medical procedure and it’s use in a vulnerable population. It is not an implication that individuals who undergo and regret medical transgender treatment are harmed to the same extent as lobotomized patients. Detransitioning individuals, even when they regret some or all of their medical transition, still have very bright and hopeful futures with great potential for healing and meaning-making.
My source for research on lobotomy:
Elliot Valenstein is an expert in the field of brain stimulation and psychosurgery. In addition to being an author, Valenstein is a psychology and neuroscience professor. Psychosurgery is a broad category of brain surgeries that aim to alter mental illness, mood, or personality by destroying brain tissue. During his research in 1981, Valenstein discovered that lobotomy (a radical and devastating type of psychosurgery developed in the 1930s), rather than having been practiced in the margins, was part of mainstream psychiatry in the late 1940s. Becoming interested in how this came to be, Valenstein researched the rapid rise of lobotomy and published his book in 1986.
As I read this heavily researched and horrifying history, I was struck by many parallels between lobotomy and childhood gender transition. In this post, I lay out some of these similarities.
I will include hyperlinks to all sources and include images from the book’s text.
The Ingredients for a Medical Scandal
Ambitious, risk-taking pioneers
Lobotomy was based on a vague theory that mental illness is located in specific brain regions. This theory was proposed by a highly ambitious Portuguese physician, Egaz Moniz, who primarily strove to become famous for developing novel medical procedures. Though Moniz was struggling to create a breakthrough cerebral arteriography imaging, he got the idea of performing lobotomy on humans while attending a lecture on a primate frontal lobe lobotomy study. He went on to extrapolate brain mechanisms for emotional agitation, and then attempted to apply these to human psychological distress. In fact, the primate studies that served as the foundation for this theory were misinterpreted and misrepresented in order to justify lobotomy. In 1949, Moniz was awarded the Nobel Prize for developing prefrontal lobotomy.
Had Moniz been more humble and curious about the contextual outcome of the primate lobotomies, which left the animals in a highly deteriorated state, he never would never have been able to justify performing these surgeries on humans.
Walter Freeman was the US physician who worked tirelessly to popularize lobotomy in the US. He would later come to develop his own procedure, known as ‘ice pick lobotomy,’ based on the notion of separating the “feeling parts” of the brain from the “thinking parts”.
Freeman was known to be a dynamic showman who went out of his way to attract public attention with shocking demonstrations, weekend clinics and live cadaver dissections.
The two main leaders of the lobotomy movement were both innovative, ambitious, and seemed to show very little concern about the risks of pioneering new experimental procedures.
While there are many individuals and organizations responsible for the mainstreaming of medical transition for youth, I’ll focus on just a few throughout this piece.
Norman Spack is a pediatric endocrinologist at Boston’s Children Hospital and the co-founder of the hospital’s Gender Management Service clinic. Similar to Moniz’s spark of curiosity at the lobotomized chimpanzee demonstration, Spack began “salivating’’ when he learned at a meeting in Europe, about blocking children’s puberty in early adolescence. The outcome of a child’s infertility isn’t reason enough to stop Spack from recommending early hormonal interventions.
In the following TED Talk, Spack tells the story of his patient, a gender dysphoric natal male child. The child was predicted to grow to be 6’5’’ and Spack tried something innovative and risky. He not only blocked the child’s puberty, but also put him on estrogen at the young age of 13 (typically this step is reserved for 16 year olds). Spack goes on to boast that at age 16, the teen was then able to go to Thailand to have the male genitals turned into a neo-vagina.
TED Talk: https://bit.ly/334jQk5
An ambiguous theory of distress & mental illness
To justify using lobotomy, advocates had to continue developing the theory of psychological distress as a medical issue that is only resolvable by surgical means. In order to respond to critique from the psychological community, the medical theory of distress used psychoanalytical language to explain the need to destroy brain tissue. They sometimes leaned on better-formulated scientific theories, without connecting those to their own novel ideas.
Moniz, in trying to validate lobotomy, referenced the work of Ramon y Cajal, a specialist on the nervous system:
Dr Dianne Ehrensaft is a psychologist who works closely with Norman Spack and she has developed a theory of “Gender Creativity” and “Gender Spectrum” which is used to justify “social transition” and medically altering children’s bodies to fit with their “gender identity.” “Gender Smoothies” and “Gender Oreos” seem particularly absurd. She also notes that often, girls who identify as lesbian later come out as boys, but this is no reason to be skeptical of their “true gender self”.
Ehrensaft explaining these categories in a YouTube video: https://bit.ly/3bv0YPh
Using the language of psychoanalyst and pediatrician, Donald Winnicott, but applies it to her own theory of the “false gender self”:
The graphics below do not come directly from Ehrensaft, but they are commonly used in training by gender organizations to explain the theory of gender identity to medical and psychological providers. School programs use these to “educate” children, teachers, and school counselors.
A revolutionary feeling in the air, with little reason for skepticism:
Lobotomy was an exciting new procedure. With showmen like Moniz and Freeman establishing relationships with journalists and media outlets, news of the miracle cures spread quickly.
Furthermore, few of the media articles indicated any reasons for readers to be skeptical or hesitant about the lofty promises of the surgeons. This led to largely uncritical acceptance of their interventions by much of the public and medical establishment.
From a Newspaper article on lobotomy:
The “Gender Revolution” has been largely expanded by both media stories and the adoption, by medical and psychological establishments of this new theory of gender. There are literally countless new organizations and gender-education groups which promote these theories of identity.
National Geographic Magazine:
From the American Psychological Association:
Focus on intervention, not assessment:
The role of the physician, according to lobotomy advocates, was to learn the surgical technique. While the type of patient predicted to benefit from the procedure changed over time, there was a consistent lack of assessment to determine patient appropriateness. The evaluation was left to the referring psychiatrist, and ease of performing the procedure was emphasized:
The same lack of assessment is obvious to anyone following the issue of gender affirmative care. When a patient mentions a gender concern to their therapist, they are typically referred to a gender clinic or “gender expert,” which sees its role as the provider of intervention, and not as a safeguarding agent or gatekeeper:
In the following case, a natal male cancer patient (re-named, ‘Iris’) with extensive medical trauma, cognitive disability, anxiety disorder, and clinical depression was able to receive estrogen and medical transition upon claiming a transgender identity at Seattle Children’s Gender Clinic. There seems to be no curiosity about whether these other complications, or even puberty itself, may have contributed to the patient’s body discomfort.
Financial Incentives & Desperation
One of the primary factors which made lobotomy so appealing was the dire overcrowding and financial constraints of psychiatric hospitals. At the time, these institutions were horrifying places where the severely mentally ill lived in squalid conditions and were routinely abused and neglected by staff. In such a state of desperation, hospitals were willing to try anything that offered hope to either reduce the number of institutionalized patients or make current patients easier to manage. After lobotomy, previously agitated patients were sometimes able to return home to be cared for by relatives. Others, however, became completely dependent on carers (or hospital staff) as they’d lost much of their ability to function independently, work, or maintain normal lives.
A lack of resources to treat mental illness was a pre-existing issue when lobotomy was first developed. By contrast, as gender related interventions are developed for younger children, more dysphoric children seem to be created through an iatrogenic process.
In the UK since the recent surge of children seeking to transition, long waiting times at the Gender Identity Development Service (GIDS) can extend up to 2 years. The desperation and urgency of patients on the waiting list exert significant pressure on the service to turn over cases and hurry children along the transition path.
In addition to facing accusations from resigned clinicians (which I explore later), the Tavistock gender service in the UK was also accused of fast tracking children to transition because of high demand to treat a large number of patients:
An Exponential Rise:
Discarding psychological explanations for medical ones:
Lobotomy was often described as the “Surgery for the Soul,” with proponents claiming that only surgery, and not psychological intervention, could treat the mental illness.
photo above: Walter Freeman trains others in his transorbital lobotomy procedure
Moniz, the first to perform lobotomy, rejected all psychological theories for mental illness:
“Gender affirmation” surgeons insist the only way to treat gender dysphoria is by removing organs. Below is a quote from plastic surgeon, Christopher Inglefield from the London Transgender Clinic discusses patients’ body parts:
“The only established and documented cure for gender dysphoria is surgery…. We’ve removed the reason for their gender dysphoria, whether it’s their breasts, or their facial appearance, or their genitalia. We remove that…that thing which caused the gender dysphoria in the first place.”
Quote from Trans-Actions Film by Silke Steidinger: https://bit.ly/3m97KiC
Of course, dissatisfied patients of medical gender intervention, sometimes called detransitioners, question this practice:
Patient follow-up after lobotomy was both weak and too short-term to determine whether the procedure could be deemed safe or effective. After drilling 6 holes into the patient’s skull, inserting a thin metal rod with an extendable wire, he removed 6 ‘cores’ from the brain thought to be responsible for the patient’s distress. Freeman would then simply observe whether or not the patient was agitated, and ask a few simple questions:
Moniz made safety claims about the procedure without adequate follow up, even after observing unfavorable behaviors and personality changes:
Even when Freeman acknowledges that more research is needed, he still continues to promote his “cure” without hesitation:
Critics of childhood transition raise serious concern about halting natural development of the brain and body with puberty blockers:
From Gender Health Query:
From Michael Biggs’ review of the literature on puberty blocking interventions:
Jack Turban, in his own paper, acknowledged the need for more research, yet he continues to promote puberty blocking in the media:
Freeman, in the last years of his life, and on his own dime, drove to visit several thousand former patients in various locations to personally follow up and check on their outcomes. Freeman was estimated to have performed 10% of the total number of lobotomy procedures during his lifetime.
In transgender medicine, there is a notoriously large loss-to-follow up. The image below is related to adult data on male to female patients, which is a very different population from the group of mostly teen girls seeking transition today.
Loss to follow up:
The long term data on adult Male to Female transition also shows unsatisfactory outcomes:
Earlier, more drastic intervention and the threat of suicide:
To me, the most shocking similarity is that advocates of both lobotomy and childhood transition gravitated to more extreme and earlier forms of intervention over time. Both eventually claim that not intervening could lead to patient suicide. Allowing a natural course of symptom development and resolution or taking a conservative, less-is-more approach have been deemed dangerous by both the zealous lobotomy and childhood transition advocates:
If a first lobotomy didn’t produce desirable results, Moniz would perform a 2nd and sometimes 3rd lobotomy on the same patient. He soon began recommending lobotomy earlier and earlier, rather than waiting for patients to “deteriorate” into severe mental illness.
In his later years, as his career was in decline, Freeman presented on lobotomy in children, who he claimed, couldn’t be helped by psychotherapy. The youngest he operated on was 12 years old. Note that in the face of criticism, he became upset and insisted that he gets Christmas cards from happy patients.
Pediatric Endocrinologist, Dr. Ximena Lopez, who specializes in youth gender transition, acknowledges the controversy but goes on to explain in the same article how grateful families are for her medical care:
Johanna Olson-Kennedy presents data on double mastectomy for females as young as 13 years old:
Babies between the age of 1-2, according to Ehrensaft, are “action oriented” in how they communicate their “gender.” A female baby tearing barrettes out of her hair is sending a “gender message” that she is not actually a girl.
In the video below, Olson-Kennedy explains how much push-back she has received for her proposed early interventions, but with continued revisions to the Standards of Care, this push-back diminishes. She remembers one particular year at the WPATH conference when her recommendation for medical intervention before the age 16 was received with some hesitation, but the following year, members were disappointed in having to wait till a child is 16 to medically intervene.
Lobotomy and transition both said to save patients from suicide:
Will symptoms remit on their own?
Critics of both lobotomy and childhood transition have pointed out that symptoms are likely to remit on their own if left untreated and question whether a patient is truly impaired enough to require such a drastic intervention
Depression will disappear spontaneously (re lobotomy):
Perhaps not ill enough to require intervention:
One example of such a case might be Carolyn. She was a college student whose parents annulled her marriage to the man she loved dearly. This triggered her mental distress and she was later lobotomized:
Ryan Barnes is a detransitioning woman who prescribed testosterone when she claimed to be a man. Her path to identifying as a transman started during her teen years when she wasn’t interested in romance or sex. She thought that meant something was wrong with her. She then tried to find the right sexual or gender label by experimenting with various sexuality and gender identities she learned online. Ultimately, this led her to identify as a man and she was put on testosterone for one and a half years till she began to question her transition.
From experimental to an urgent first-line-of-defense – doing nothing becomes dangerous:
Freeman warns that patients should have a lobotomy “before it’s too late”:
In response to critiques about his lack of caution, Moniz says that doing nothing is inexcusable (in addition to stringing together some incoherent jargon):
Olson-Kennedy says puberty is dangerous for “trans kids” and that doing nothing is inexcusable.
From another article:
Marianne Oakes, another childhood transition advocate:
What about etiology?
Other notable critiques of the ‘organic’ theory requiring lobotomy relate to its inability to address etiology, which may be psychic and not actually medical. Critics accuse the surgeons of being ignorant of “mental hygiene,” or the practice of achieving wellness through proactive behavioral and psychological treatment:
Marcus Evans points out the psychic turmoil of adolescence as a possible cause for body discomfort:
Responding to the critics
True believers of both procedures dismiss the critics as ignorant or simply unenlightened. The crusade continues, and “education” and promotion forge ahead.
Olson-Kennedy can be heard here minimizing the risk of transitioning children who won’t actually benefit or remain identified as transgender. She insists that she and others just need to keep explaining it to those who are skeptical:
Critics of lobotomy warn that all less invasive interventions should be exhausted first and point out the negative impact of the procedure:
Dr David Bell, a senior consultant at the Tavistock & Portman NHS Trust comments on the gender service:
The near silence from youth transition advocates on the topic of detransition is telling. Here Jack Turban makes a dismissive statement about the “purely cosmetic” effects of medical transition:
Thousands of detransition stories can be found online. Here’s one example of an autistic woman explaining how the theory of “gender identity” prevented her from understanding herself. Gender theory caused her to attribute the traits of her neurodevelopmental condition to having “a male brain.” Of course, being put on testosterone didn’t help her:
This woman describes the profound sadness over having her breasts removed when she identified as a man:
And here one of many posts by detransitioners who feel mislead by the medical community that encouraged them to transition:
Keira Bell, a detransitioner in the UK who is a claimant in a court battle over the safety of puberty blockers.
“Keira blames the treatment that began at the Tavistock in North London when, at 16, she no longer wanted to be a girl and asked for help. After three one-hour appointments, she was prescribed hormone blockers to halt the development of her female body. Put on what she calls a ‘roller coaster’ journey, she was soon being given the male hormone testosterone to change her appearance. Three years ago, she had her breasts removed, in an operation paid for by the NHS.
Despite that dramatic step, this story has taken an extraordinary twist. For Keira has now changed her mind about being a man. She believes it is an impossible quest, and is trying to reverse the process.”
Zero Scientific Value
Serious examination of the current data shows little scientific value for either lobotomy or youth medical transition:
Study Correction for “Gender-Affirming” Surgeries:
From an analysis by J.L. Cederblom of Cornell University’s “What We Know” policy document supporting gender transition:
The beginning of the end – restricting the crusaders:
The introduction of psychotropic medication, and the effectiveness of critique eventually brought psychosurgery to its end. But Walter Freeman persisted in his use of transorbital lobotomy:
Even when legally denied permission to practice, gender docs find other ways to continue medicalizing children:
Critical editorials gain more public attention:
Dr David Bell encourages more critical discussion of the practice of transitioning children:
To learn more about how lobotomy finally came to an end, I highly recommend Valenstein’s book.
He ends with a sobering reminder that with any medical advancement, completely avoiding risk is impossible. I don’t doubt that many doctors advocating childhood transition truly believe this is in the child’s best interest. This sense of belief and conviction, then, is even more reason to be diligent with data collection and empirical evidence:
We may be seeing some of the signs of childhood transition slowing down, especially in the UK. But here in the US there are approximately 65 youth gender clinics operating today, and approximately 650 informed consent clinics for adults 18 years of age and older.
As the children being experimented on in this decade grow up and reach maturity, we may see the physical and psychological consequences of this wide-scale medical scandal. I hope we can pause and recommit to more rigorous ethical and safety standards soon, before more young lives are impacted.