Some critics describe the kind of treatment offered at places like the Transgender Center where I worked as a kind of national experiment. But that’s wrong. Experiments are supposed to be carefully designed. Hypotheses are supposed to be tested ethically. The doctors I worked alongside at the Transgender Center said frequently about the treatment of our patients: “We are building the plane while we are flying it.” No one should be a passenger on that kind of aircraft.

I am a 42-year-old St. Louis native, a queer woman, and politically to the left of Bernie Sanders. My worldview has deeply shaped my career. I have spent my professional life providing counseling to vulnerable populations: children in foster care, sexual minorities, the poor.
For almost four years, I worked at The Washington University School of Medicine Division of Infectious Diseases with teens and young adults who were HIV positive. Many of them were trans or otherwise gender nonconforming, and I could relate: Through childhood and adolescence, I did a lot of gender questioning myself. I’m now married to a transman, and together we are raising my two biological children from a previous marriage and three foster children we hope to adopt.
All that led me to a job in 2018 as a case manager at The Washington University Transgender Center at St. Louis Children’s Hospital, which had been established a year earlier.
The center’s working assumption was that the earlier you treat kids with gender dysphoria, the more anguish you can prevent later on. This premise was shared by the center’s doctors and therapists. Given their expertise, I assumed that abundant evidence backed this consensus.
During the four years I worked at the clinic as a case manager—I was responsible for patient intake and oversight—around a thousand distressed young people came through our doors. The majority of them received hormone prescriptions that can have life-altering consequences—including sterility.
I left the clinic in November of last year because I could no longer participate in what was happening there. By the time I departed, I was certain that the way the American medical system is treating these patients is the opposite of the promise we make to “do no harm.” Instead, we are permanently harming the vulnerable patients in our care.
Today I am speaking out. I am doing so knowing how toxic the public conversation is around this highly contentious issue—and the ways that my testimony might be misused. I am doing so knowing that I am putting myself at serious personal and professional risk.
Almost everyone in my life advised me to keep my head down. But I cannot in good conscience do so. Because what is happening to scores of children is far more important than my comfort. And what is happening to them is morally and medically appalling.
The Floodgates Open
Soon after my arrival at the Transgender Center, I was struck by the lack of formal protocols for treatment. The center’s physician co-directors were essentially the sole authority.
At first, the patient population was tipped toward what used to be the “traditional” instance of a child with gender dysphoria: a boy, often quite young, who wanted to present as—who wanted to be—a girl.
Until 2015 or so, a very small number of these boys comprised the population of pediatric gender dysphoria cases. Then, across the Western world, there began to be a dramatic increase in a new population: Teenage girls, many with no previous history of gender distress, suddenly declared they were transgender and demanded immediate treatment with testosterone.
I certainly saw this at the center. One of my jobs was to do intake for new patients and their families. When I started there were probably 10 such calls a month. When I left there were 50, and about 70 percent of the new patients were girls. Sometimes clusters of girls arrived from the same high school.
This concerned me, but didn’t feel I was in the position to sound some kind of alarm back then. There was a team of about eight of us, and only one other person brought up the kinds of questions I had. Anyone who raised doubts ran the risk of being called a transphobe.
The girls who came to us had many comorbidities: depression, anxiety, ADHD, eating disorders, obesity. Many were diagnosed with autism, or had autism-like symptoms. A report last year on a British pediatric transgender center found that about one-third of the patients referred there were on the autism spectrum.
Frequently, our patients declared they had disorders that no one believed they had. We had patients who said they had Tourette syndrome (but they didn’t); that they had tic disorders (but they didn’t); that they had multiple personalities (but they didn’t).
The doctors privately recognized these false self-diagnoses as a manifestation of social contagion. They even acknowledged that suicide has an element of social contagion. But when I said the clusters of girls streaming into our service looked as if their gender issues might be a manifestation of social contagion, the doctors said gender identity reflected something innate.
To begin transitioning, the girls needed a letter of support from a therapist—usually one we recommended—who they had to see only once or twice for the green light. To make it more efficient for the therapists, we offered them a template for how to write a letter in support of transition. The next stop was a single visit to the endocrinologist for a testosterone prescription.
That’s all it took.
When a female takes testosterone, the profound and permanent effects of the hormone can be seen in a matter of months. Voices drop, beards sprout, body fat is redistributed. Sexual interest explodes, aggression increases, and mood can be unpredictable. Our patients were told about some side effects, including sterility. But after working at the center, I came to believe that teenagers are simply not capable of fully grasping what it means to make the decision to become infertile while still a minor.
Side Effects
Many encounters with patients emphasized to me how little these young people understood the profound impacts changing gender would have on their bodies and minds. But the center downplayed the negative consequences, and emphasized the need for transition. As the center’s website said, “Left untreated, gender dysphoria has any number of consequences, from self-harm to suicide. But when you take away the gender dysphoria by allowing a child to be who he or she is, we’re noticing that goes away. The studies we have show these kids often wind up functioning psychosocially as well as or better than their peers.”
There are no reliable studies showing this. Indeed, the experiences of many of the center’s patients prove how false these assertions are.
Here’s an example. On Friday, May 1, 2020, a colleague emailed me about a 15-year-old male patient: “Oh dear. I am concerned that [the patient] does not understand what Bicalutamide does.” I responded: “I don’t think that we start anything honestly right now.”
Bicalutamide is a medication used to treat metastatic prostate cancer, and one of its side effects is that it feminizes the bodies of men who take it, including the appearance of breasts. The center prescribed this cancer drug as a puberty blocker and feminizing agent for boys. As with most cancer drugs, bicalutamide has a long list of side effects, and this patient experienced one of them: liver toxicity. He was sent to another unit of the hospital for evaluation and immediately taken off the drug. Afterward, his mother sent an electronic message to the Transgender Center saying that we were lucky her family was not the type to sue.
How little patients understood what they were getting into was illustrated by a call we received at the center in 2020 from a 17-year-old biological female patient who was on testosterone. She said she was bleeding from the vagina. In less than an hour she had soaked through an extra heavy pad, her jeans, and a towel she had wrapped around her waist. The nurse at the center told her to go to the emergency room right away.
We found out later this girl had had intercourse, and because testosterone thins the vaginal tissues, her vaginal canal had ripped open. She had to be sedated and given surgery to repair the damage. She wasn’t the only vaginal laceration case we heard about.
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If we fixate upon the tone of the service—stamping out laughter and mirth—making sure we have the proper atmosphere of being around the holy, we’ll never arrive at anything more than contrived stillness. Because when you focus upon being blood-earnest you’re no longer really preaching.

C.S. Lewis once spoke about the difficulty of sustaining worship. Worship by it’s very nature is a looking outside of ourselves. As soon as we start thinking about worship we end up not worshipping, this is how Lewis said it:
The perfect church service would be the one we were almost unaware of; our attention would have been on God. But every novelty prevents this. It fixes our attention on the service itself; and thinking about worship is a different thing than worshipping.
I was thinking about that Lewis quote recently while thinking through this address by John Piper on The Gravity and Gladness of Preaching. Piper is trying to make an argument for a seriousness to our preaching that conveys both the gladness and happiness and joy that we have in Christ but which moves away from frivolity or levity.
I’ve gleaned so much from John Piper over the years. I believe his blood-earnestness in preaching has had such a great impact upon me. The seriousness with which he considers the glory of God is helpful and challenging. And that is, I believe, what Piper is attempting to communicate in this lecture on preaching.
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As a church struggles—and every true church must struggle—heaven’s stairway joins her to heaven and all heaven’s mercy and safety. The stairway is not built by our faithfulness, but God’s promise. The stairway is not our obedience and steadfastness, but the person of Christ come down to rescue us from our sin and rebellion.

Weeks after winning my license, I crashed my car. It was a wet night and my friends and I decided it would be fun to drift around corners with wheels spinning. I lost control, the front of the car hammered into a high curb, and the steering was wrecked.
I limped the car home, too ashamed and embarrassed to tell my parents. I drove it first thing in the morning to the repairers in town. The mechanic hoisted it up and showed me how I’d bent the wheels and steering arms. Repair would be very costly.
I remember pacing the wet streets car-less, wondering where on earth I would find the repair money and still too ashamed to tell my family. For just a few hours I felt unusually helpless, almost nauseous with worry and loneliness. Looking back, I see how unnecessary my suffering was. All the help in the world was all around me, and I was blind to it.
So it is with Jacob in the book of Genesis.
Jacob left Beersheba and went toward Haran (Gen. 28:10).
What tragedy we read in these few words. Jacob was born into a rich and loving family. But he tricked his twin brother out of his birthright (Gen. 25) and then pulled a seriously devious and nasty deception on his blind father, tricking Isaac into giving him Esau’s covenant blessing (Gen. 27). So now Jacob is fleeing Beersheba, his home in the south of the Promised Land, to Haran in the strange and distant north: beyond Galilee, beyond Syria and Damascus, right up near Assyria and the Euphrates River.
Jacob means “Grasper.” Grasper had betrayed his family. And by lying and cheating and dishonoring his father, he had also dishonored God. What had he accomplished? A family in humiliation and disarray. He himself running, alone, and far, far from home.
Remember, this is the father of Israel. According to the principle of corporate identity as explained in Hebrews 7:1-10, the entire nation was physically latent within him at that moment. Jacob is Israel. Grasper personifies the church. What is true of him is true of the church.
What is true of Jacob is true of the church.
And he came to a certain place and stayed there that night, because the sun had set. Taking one of the stones of the place, he put it under his head and lay down in that place to sleep (Gen. 28:11).
After fleeing all day, night falls with no motel or friendly house nearby. In verse 20 Jacob prays for “food to eat and clothes to wear.” So we see a lonely, guilty, destitute man. He lies in the open air with a rock for a pillow. He is exhausted physically, morally, spiritually, and relationally. This by nature is you. This by nature is your church.
Sleeping on rocks gives anyone strange dreams. God gives Jacob a vision. It is a kind of apocalypse; God pulls aside the curtain to show Jacob what is going on behind his desolate circumstances.
God showed Jacob a staircase joining heaven and earth.
And he dreamed, and behold, there was a ladder set up on the earth, and the top of it reached to heaven. And behold, the angels of God were ascending and descending on it! And behold, the Lord stood above it and said, “I am the Lord, the God of Abraham your father and the God of Isaac” (Gen. 28:12-13a).
God cast our rebellious parents, and thus us, out of Eden. Cherubim wielding blazing swords barred the way back (Gen. 3:24). Humanity, and not least Jacob at this point, live within the desolation of that separation. But God showed Jacob a staircase joining heaven and earth.
The people of Babel attempted something like this, to build a tower to reconnect heaven and earth, to manufacture greatness and security (Gen. 11:1-9). But it was human-made and prideful, and God razed it. If God separated humanity from heaven, what can we do to bridge the gulf?
We cannot reach up to God, but he can reach down to us. That is the staircase.
Why are angels dashing up and down it? “Are they not all ministering spirits sent out to serve for the sake of those who are to inherit salvation?” (Heb. 1:14). They rush down with God’s word and salvation (Heb. 2:2), and rush back up with our prayers (Rev. 8:4). The staircase establishes communication between Jacob and heaven. It is a conduit of help—of salvation.
The One who speaks to Jacob is “the Lord, the God of Abraham your father and the God of Isaac.” He made that unbreakable promise to Abraham:

“Now the Lord said to Abram, “Go from your country and your kindred and your father’s house to the land that I will show you. And I will make of you a great nation, and I will bless you and make your name great, so that you will be a blessing.” (Gen 12:1-2) 

At that point Jacob must have doubted those promises. “Land? Great nation? Great name? Blessing? I’m an exile from the land. My ‘great name’ is Grasper. I’m cursed, not blessed!” Jacob had betrayed family and God and had lost everything. Yet God was working right then even in Jacob’s betrayal and desolation to fulfill his promise. God was there, heaven and earth were joined. God’s ministering servants rushed up and down for Jacob.
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