Nothing to See Here

A couple of weeks ago, I attended a grand round with a leading gender clinician in my city. Let’s just say it was interesting.

The presentation began with an obligatory performance of humility in the face of marvels: “When I got started, I made a lot of mistakes,” he said. In particular, he made mistakes when it came to working with youth who’d adopted “categories that nobody else would understand, like a bigender genderqueer mystical teen. Is that a category I can use in any way? Is there anything objective attached to those words that I can say, OK, I’m going to follow this piece of it?”

This, of course, was the mistake: thinking it was his place to evaluate and understand. Thinking it was his place to pin his medical practice on something objective:

“I had to get past my biases when I started working with this population. I had to get a point where I could say: I don’t know what to do with this but it doesn’t matter, that’s just how they self-identity.”

(It’s not that there’s no gatekeeping in the world of gender affirmation. “If somebody self-identifies as two-spirit, ask if they have First Nation status and if they know what that means, otherwise maybe they’re using that term incorrectly.”)

“Ultimately, we need to go down to phenomena and be phenomenologists.”

But rather than dwell on phenomenology—which I agree would be a fascinating and potentially fruitful way to approach a mind-body disconnect like gender dysphoria—he moved on quickly to the preoccupations of the days: the critiques he sees arrayed against the kind of ‘care’ he provides.

He started in on the (lack of) evidence supporting puberty suppression. Rather than talk about the unknowns—briefly acknowledged, hastily dismissed—he zeroed in on bone density. “You have to ask: are [patients] Asian? Are they European? Then they’re already at risk for osteoporosis. [Puberty suppression] is not a greater risk than being Japanese.”

Besides, he added, “There’s no risk of osteoporosis if they start [cross-sex] hormone therapy. Then that risk gets taken away.” Patients know if “puberty isn’t working for me.” The questions clinicians must ask themselves run along the lines of “Do [patients] feel better if we lower their hormone levels? Do they say, ‘I’m not as dysphoric about things because I know I stopped things here, I can handle it here, I was panicking about things getting further along the way…’?”

And surgeries on minors? “Those surgeries don’t happen,” he assured the audience. “Are there places where they have been a little bit younger? Sure.”

Finally, he moved on to his sore points: detransition—or, as he calls it, ”detransition/retransition”—and the accusation that clinicians like him are “transing the gay away.”

“I don’t want to belabor [detransition] because we had a discussion about that last time—”—it was unclear what ‘last time’ he was referring to—“—but detransition and retransition are part of the broader umbrella of gender-atypical patients and part of the broader umbrella of trans patients. Patients who are trans, detrans, and retrans are all essentially trans patients because they’re doing gender exploration.” He created a clinical and moral equivalence between transition and detransition. Facilitating a patient’s flight from her body through drugs and surgery is the same as facilitating a return.

“Is there an endpoint for gender identity?” he asked. “Does it matter?”

He sounded like a freshman in a philosophy seminar, not someone who works with powerful drugs and surgical instruments.

As far as the overrepresentation of gay kids in gender clinics goes, he showed genuine offense. These concerns are a “kind of medieval thinking.” His face twisted with disgust. “The suggestion that someone is so interested in not being gay that they would go through years and years of other challenges like medical and surgical interventions in order to not be gay…?” he trailed off, not finishing the sentence.

He couldn’t cope with the counterarguments, so he fashioned a strawman and savaged it instead: “Very few patients are covering up their homosexuality by pretending to be trans.” But who accused patients of “covering up their homosexuality,” as opposed to being confused or genuinely interpreting same-sex attraction as a sign they’re transgender? “It’s very irresponsible to let that myth [that gay kids are being transitioned] be propagated. It’s almost unheard of. You can nip that in the bud… Maybe there’s a kid who is bisexual who thinks they’re bigender and then you just make sure they know what the terms are… but a kid functioning at an average IQ will be able to understand that…”

A few minutes of floundering and the clock ran out, sparing him.

He doesn’t see what he does. From his barely contained rage, it’s clear he doesn’t want to see. He bristles with resentment at the people who try to open his eyes, who tell him a different story than the one he tells himself. He sees himself as a life-saver. They want to write him into a story about medical harm. But surely a doctor’s most basic responsibility is to see and understand what he does, so that he can judge whether what he does is ethical or not, whether he helps the patient or harms the patient.

He doesn’t seem to see that either gender dysphoria is a medical condition with a medical treatment, in which case there are standards for assessment and care and accountability for bad outcomes like medical harm and regret—or it’s not, in which case, he doesn’t get to say it’s life-saving.