"WE'RE ALL JUST WINGING IT": WHAT THE GENDER DOCTORS SAY IN PRIVATE

 The Free Press

 

‘We’re All Just Winging It’: What the Gender Doctors Say in Private

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

By Leor Sapir

12.03.25 —

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

A Major Strategic Blunder

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

“Wing It Together”

 

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

 

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

 

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

 

A video obtained exclusively by The Free Press shows what clinicians say behind closed doors:

 

WPATH updates its “Standards of Care” on an irregular basis, and 2022 was the year it released the eighth version. This revision added some new chapters, including one called “Nonbinary.” WPATH defines the term capaciously.

 

To be nonbinary, the Standards of Care explain, one need only have an “internal sense of gender” that is at odds with social expectations associated with one’s “assigned sex.” This includes “indigenous and non-Western genders” as well as “people whose genders are comprised of more than one gender identity simultaneously or at different times (e.g., bigender), who do not have a gender identity or have a neutral gender identity (e.g., agender or neutrois), have gender identities that encompass or blend elements of other genders (e.g., polygender, demiboy, demigirl), and/or who have a gender that changes over time.” One case, discussed by OHSU gender clinicians, involved a teen who said that he realized “Frank-N-Furter” from The Rocky Horror Picture Show was his gender identity.

 

The Standards of Care state that nonbinary was a fast-growing area of transgender identification, comprising an estimated 25 to 50 percent of the transgender population, and particularly high among the young.

 

The video of the 2022 WPATH conference in Montreal features a presentation by three contributors to the “Nonbinary” chapter: Belgian psychologist Joz Motmans, British endocrinology consultant Leighton Seal, and American psychologist Laura Kuper.

 

During the Q&A portion of the session, a woman who said she worked at a gender surgery center asked why the contributors recommended that those seeking nonbinary procedures should first consult with a “multidisciplinary team.” The questioner pointed out that this provision was in tension with WPATH’s professed goal of eliminating barriers to all forms of medical “affirmation.” Having to go through a consultation with several medical professionals, she complained, felt “more restrictive.”

 

Seal explained that this recommendation was largely out of concern for the protection of his fellow practitioners. He noted that some patients will inevitably regret their procedures, and “if you have a network around you where a clinical team, in concert with the individual, has made a decision, you then have a framework to say, ‘Well, the ethics of this were explored. . . ’ ”

 

Seal acknowledged that interventions are based on little to no evidence of efficacy. He said, “[W]e are doing procedures here where we don’t have outcome data. So unless you want to go to individual ethics boards in each hospital to get ethics permission to do those surgeries because they’re on the edge of the field of medicine, you need to have a mechanism around you to support you. Otherwise, you could be vulnerable. That’s our feeling.”

 

One 13-year-old boy and his parent, who both identified as nonbinary, were “surprised” to hear that hormones could compromise his future fertility.

 

Indeed, a growing number of young people who have undergone various hormonal and surgical interventions are going public about being harmed physically and psychologically. Some, known as “detransitioners,” seek to reverse or mitigate the effects of medical transition. Some, having undergone a mastectomy at the outset of puberty or having damaged their bodies with hormones, are suing their medical providers, saying that they were misled about the need for and consequences of transition.

 

(WPATH’s Standards of Care don’t have much to say about detransitioners. There is no chapter for them, and WPATH asserts, falsely, that detransition “appears to be rare.”)

 

At the end of Seal’s session, a clinician from Utah said that she, too, was seeing people seek nonbinary interventions at a “dramatically increased” rate. And she wasn’t sure what to offer them.

 

The clinician emphasized that she had no problem with the novelty of nonbinary procedures. She even liked the idea of making a kind of “Pinterest board” of gender procedures that could be offered, according to the video.

 

She said that she sometimes felt like saying that both she and other WPATH clinicians were making it up as they went along: “Because I feel like we’re all just winging it, you know? And which is okay, you’re winging it too. But maybe we can just, like, wing it together.”

 

Getting More Surgeons on Board

 

We don’t know what happened to Sky. But we do know about young people like him who have had the genital-erasing surgery Sky was seeking.

 

Another new chapter in the 2022 revision of WPATH’s Standards of Care is “Eunuchs.” WPATH defines eunuchs as “those assigned male at birth (AMAB) [who] wish to eliminate masculine physical features, masculine genitals, or genital functioning.”

 

Eunuchism is documented throughout history, typically as a form of punishment or enslavement—or even to keep a young male singer’s voice from maturing. WPATH has reframed the desire for castration as a gender identity. Eunuchs, the Standards of Care explain, “may be aware of their identity in childhood or adolescence.” And like other “transgender and gender diverse” people, eunuchs are a “marginalized” group.

 

At WPATH’s 2022 annual conference, two contributors to the Eunuch chapter, Thomas W. Johnson, a professor emeritus of anthropology at California State University, Chico, and Michael S. Irwig, a physician with Beth Israel Deaconess Medical Center in Boston, presented their work. (This video was first released by journalist Wesley Yang.) Johnson explained that the causes of eunuch identity include “desire to be not male, but. . . not. . . female either,” [or] “feeling that [one’s] genitals are not a proper part of [one’s] body” and “an extreme fetish or paraphilic disorder.”

 

Irwig, an endocrinologist, said that he became interested in this topic because “a lot of eunuchs do get castrated” and seek ongoing treatment from doctors like him.

 

During the Q&A session of the eunuch talk, the only objection came from an audience member who thought Johnson and Irwig’s use of the word castration was “stigmatiz[ing].”

 

Another audience member, Thomas Satterwhite, a prominent gender surgeon, recalled how Johnson helped him overcome his doubts ahead of the first castration he performed on a gay man. “Since then, I do perform a fair number of these procedures as well as other forms of genital and gender-affirming surgery that’s, um, quote, unquote, nonstandard,” Satterwhite said.

 

Satterwhite, who founded Align Surgical Associates in San Francisco, a private clinic specializing in gender surgery, wanted to know how the field can “get more surgeons on board” with such procedures. Irwig responded that the inclusion of a Eunuch chapter in WPATH’s latest Standards of Care, “is so huge because it’s now in the official guidelines.” There are, Irwig said, a lot of doctors and surgeons who don’t want to be seen as being “rogue and doing things that. . . may get them into trouble or that. . . may get their licenses pulled.”

 

The new guidelines, he said, help “alleviate some of their concerns.”

 

The Free Press sought comment from WPATH and the individuals who spoke in the videos cited in this article. OHSU, on behalf of its clinicians, declined to comment. Johnson said he stood by his remarks but added that paraphilia is a better word than fetish for describing one cause of eunuch identity. The others did not respond.

 

A New Era

 

The origin of pediatric gender transition began in the late 20th century as a cosmetic solution to a psychological problem. Until then, the entire field of gender medicine was tiny and primarily focused on “adult transsexuals.” These were largely middle-aged men seeking to pass as women.

 

The Dutch clinicians who first proposed medical transition for minors did so after observing that although the adult males said they were mostly satisfied with their decision to undergo procedures, their life circumstances had not always improved. The Dutch clinicians theorized that that was partly because of the difficulty of passing as female after experiencing the effects of male puberty, which left them with features such as broad shoulders and deep voices.

 

So the Dutch clinicians came up with a solution. What if they identified so-called “juvenile transsexuals” early in life, before the “wrong” puberty permanently altered them? What if they blocked a boy’s puberty, then put him on estrogen, followed by genital surgery, so that he could cosmetically pass as female as he entered adulthood?

 

In the 1990s, they put this idea into practice in what became known as the Dutch Protocol. Though never subjected to rigorous testing, it spread rapidly throughout the Western world. The word transsexual was discarded, and transgender became a catchall term for anyone whose “inner sense of gender” was at odds with the sex they were “assigned at birth.”

 

Then in the second decade of the 21st century, there began an unprecedented rise in adolescents—mostly teenage girls, many with emotional and psychological problems—declaring they were trans. Many had no childhood history of gender dysphoria. But they sought powerful male hormones—administered at six to 100 times the normal range for girls their age—and surgeries to remove their healthy breasts.

 

At the same time, a focus on identity began to consume liberals across the West, and trans advocates in medicine began embracing a new treatment goal that now regarded assimilation as a perceived member of the opposite sex as entirely optional.

 

The thinking went like this: Since “gender binary” is an oppressive social construct “rooted in colonialism” (as one WPATH speaker put it), why encourage teens to conform to it? According to OHSU’s Jess Guerriero, a social worker at the Doernbecher Children’s Hospital gender clinic, who spoke at WPATH’s 2021 conference, clinicians should “actively challenge” gender norms and prioritize “authenticity instead over assimilation.”

 

By the time WPATH’s 2022 Standards of Care were published, many practitioners attending the organization’s conference fully embraced the idea that wanting to alter one’s body to match one’s gender vision was primarily a matter of aesthetics and self-expression. The diagnosis and treatment of possible mental health issues took a back seat.

 

In 2024, Annelou de Vries, the leading figure behind the original Dutch Protocol, co-authored a paper in BMC Medical Ethics arguing that the field of gender medicine should move beyond the “logic of improvement,” which states that medical interventions are justified if they credibly result in mental-health benefits.

 

De Vries and her co-authors cited the work of Florence Ashley, a Canadian jurist who identifies as transgender and who has put the matter even more emphatically. The goal of treatment, Ashley wrote, should be achievement of “gender euphoria” and “creative transfiguration,” which means “seeing the body as a gendered art piece that can be made ours through transition-related interventions.”

 

This new paradigm means that clinicians no longer understand themselves to be treating a mental-health condition, even if they tell insurance companies for billing purposes that’s what they’re doing. And even if they tell parents of minors and the public at large that the medical interventions they propose are “lifesaving.”

 

They also acknowledge, even celebrate, the precarious and unstable nature of the gender identities of many of the young people who come to them confused and distressed.

 

“We understand that gender expression and gender identity are very individualized and. . . may change over time,” said Guerriero. “And we want to be part of that journey.”

 

A consistent theme in the WPATH videos is that whatever gender clinicians tell the outside world, in their own internal discussions many freely and proudly proclaim that they conduct no assessments, either of mental health or even of gender identity, and base treatment considerations on an individual’s cosmetic “goals.”

 

This may result in young patients being given medical interventions that will be difficult, even impossible to undo.

 

What Now?

 

In the first days of his administration, President Joe Biden ordered the expansion of access to so-called “gender-affirming care” for minors. His administration made it a priority thereafter. After all, since 2012 Biden was calling the transgender movement “the civil rights issue of our time.”

 

But in the first few days of his second term in office, President Donald Trump signed an executive order titled “Protecting Children from Chemical and Surgical Mutilation,” which instructed the agencies of the federal government to take steps to bring the practice of medicalized transition of minors to an end.

 

Since then, the Department of Health and Human Services has published “Treatment for Pediatric Gender Dysphoria: Review of Evidence and Best Practices.” (Disclosure: I was a contributor to the report.) It came to the same conclusion as reviews conducted in several progressive European countries: The evidence for medically transitioning minors is very poor. The peer-reviewed HHS review also examined pediatric transition through the lens of widely accepted principles of medical ethics, concluding that the case against such transition is compelling.

 

The Trump administration has also threatened to withdraw federal funds from hospitals that offer hormones and surgeries to minors, subpoenaed gender clinics for information about their patients, and launched investigations of suspected insurance fraud. The Centers for Medicare & Medicaid has proposed a rule that would prohibit taxpayer-funded insurance from covering these procedures.

 

There’s reason to believe that such actions enjoy broad public support. More than seven in 10 Americans, including more than half of Democratic and Democratic-leaning voters, believe minors should not be offered puberty blockers or cross-sex hormones, according to a recent New York Times/Ipsos poll.

 

But there is the looming question of whether we will simply ping-pong between Democratic expansion and Republican restriction.

 

New York City mayor-elect Zohran Mamdani, for instance, is an advocate for youth transition. As Benjamin Ryan reported, Mamdani’s campaign promised to spend $65 million to “expand and protect gender-affirming care citywide. . . for both transgender youth and adults.”

 

Last year, after Trump was reelected, Massachusetts Democratic Rep. Seth Moulton, musing on the Republican’s victory, observed that he didn’t want his two daughters “getting run over on a playing field by a male or formerly male athlete.”

 

This subjected Moulton to a firestorm of protest by trans activists. Recently, upon announcing he would challenge Democratic senator Ed Markey, Moulton gave an elaborate apology for his defense of girls’ sports and promised he would champion Markey’s Transgender Bill of Rights, which seeks to remove restrictions on “gender-affirming care” for minors.

 

Meanwhile, WPATH shows no signs of reassessing its views—nor have the major U.S. medical associations that have embraced youth transition. Despite suffering loss after loss in the policy and public opinion arenas, WPATH continues to insist that “gender-affirming care is backed by rigorous research, expert consensus, and patient-centered values.” It vows to “stand ready to support practitioners, families, patients, and communities working to protect access to lawful care for transgender and gender diverse individuals.”

 

‘We’re All Just Winging It’: What the Gender Doctors Say in Private