Very human problems in the field of gender medicine
I wanted to respond to two major themes in the responses to my piece on the questionable beliefs and practices of gender clinicians, which can be summed up as “These people are evil” and “These people are idiots.”
I am not going to deny there are bad actors—and more than a few complete and utter nincompoops—in the field of gender medicine. But most of these people got into the field of trans healthcare in order to help people. That they wound up causing harm instead is a product of indoctrination into harm-as-help. It's not possible to understand where this field is today without understanding that.
I’ve gotten some criticism for being too soft on gender clinicians. I don’t think this is fair, exactly, but I understand where it’s coming from. I think it’s more important to understand how that happened than to label it as ‘evil,’ wash one’s hands, and be done with it. What’s happened in the field of gender medicine is a fascinating case study in human psychology: how do decent people end up doing terrible things?
Are there a lot of people in this field who should have hung on to their critical-thinking skills? Yes. But the process of enculturation in trans healthcare gets people to surrender their critical thinking in service of the cause. That's what being a good gender clinician requires.
The piece I wrote is full of examples of how this happens. You raise concerns about a patient and suddenly you're a gatekeeper, which is bad. You’re withholding life-saving medicine just because you feel a little uncomfortable about something in some patient’s case file, like an autism diagnosis or a history of self-harm.
Or you try to abide by standard medical practices and then you get berated by a patient who says she would have killed herself if some other surgeon hadn’t been willing to break the rules and cut her breasts off despite her morbid obesity and the risks that poses during sedation and recovery. Do you want to be responsible for your patients committing suicide all because of some numbers on a scale?
The amount of emotional blackmail and hostage-taking in this field is hard to convey to outsiders. It’s everywhere. Of course this kind of pressure bends clinicians who—at first contact—knew better.
The thing is, gender clinicians talk openly about this! They say, oh, when I first started seeing these patients, I was really uncomfortable with the kinds of procedures they wanted or I thought [insert eminently reasonable critique of altering the body to placate the mind here].
Then they overcame those hangups and became true trans allies who didn't put their cisheteronormative (or whatever) biases ahead of what they came—over time and under immense ideological pressure—to believe was best for their patients.
Every concession you make to this ideology binds you. Every patient you start down this pathway binds, too. It becomes harder and harder to see what you're doing because you’d have to reevaluate everything you've already done. Rare is the person who can handle this.
Meanwhile, your patients are—at least at first, at least when they're in your exam room and you’re writing out the prescription—so grateful to be getting what both you and the patient have come to believe the patient needs to make her life livable. You can give your patients exactly what they say they want and they will worship you for it. This is as rare in medicine as it is in life.
The unintended consequences pile up, but this mostly happens off stage. Most patients who come to regret transition don’t go back to the gender clinics that harmed them in the first place. The experiences of detransitioners get reduced to “talking points” and “damaging tropes,” yet another faith challenge gender clinicians have a responsibility to overcome.
The conversation about gender-affirming care within organizations like WPATH is missing something: the human level. There’s the abstract battle between the forces of affirmation and transphobia, where the right side of history picks itself, and then there are the technicalities. How to get insurers to cover a nonbinary patient’s embodiment goals. How to secure informed consent (on paper, anyway) from a complicated patient. How to stitch together a neovagina from too little penile tissue. As G. K. Chesterton observed of the eugenicists of his own time: “they have studied everything but the question of what they are studying.”
Evil? No, but dangerous.
Idiots? Not exactly.
Human? Very.
If we don't understand and accept that a large portion of the people promoting and acting on these ideas are largely driven by good intentions and their genuine belief they are saving lives, we are closing off perhaps the only pathway to getting them to see the harm they're doing and reclaiming their critical thinking skills. It understandably makes people shut down or get angry at giving anything that feels like grace to people who have done so much harm - personal harm for some of us - but ultimately all I care about is finding the fastest way to get as many of them out of this as possible.
Excellent thought-provoking piece. I'm sure you're right about human nature. It's as though the clinicians themselves have been groomed. But maybe they need the sharp slap of reality when they do harm. In other professions there is accountability. In UK for example, teachers undergo regular and rigorous OFSTED inspections. They can endure devastating criticism for failing to achieve one aspect of a list of targets. But in the UK, after the scandal of child harm at the Tavistock gender clinic, I understand that the pro-affirmation clinicians are still working and believing. They cannot pretend not to know, because there's a government inquiry into the scandal. A young person took them to court for harm and won. They must have a huge capacity for blocking out information, or feeling anything at all for their patients. You can only get so far on smugness. It would be interesting to see an analysis of the personality type. Who could persist with harming children when the evidence of serious risk is so available?