WPATH, part IV: "Nuances within the rainbow"

A.K.A. Transitioning patients even when we really, really ought to know better

This session—Understanding the Nuances Within the Rainbow: Navigating Challenging and Complex Clinical Cases—highlights the problem with framing everything as a "gender journey" upfront, as gender clinicians tend to do. It turns out there's no way to step out of this framing later, e.g., "oh, no, it wasn’t a gender journey after all, the patient was just psychotic.”

Within our model, the first thing that we usually is have individuals complete a biopsychosocial assessment that gives us a better understanding of the patient's gender journey, which can then inform ways to help achieve their goals. While about 80% of these clinical cases are fairly typical, there's about 20% that are more complex and nuanced that require some more consultation.

This quote also highlights the limitations of “biopsychosocial” assessments in gender-affirming contexts. At best, clinicians may determine that—while the patient is really trans—now is not the appropriate time for the patient to advance to the next destination on his totally valid gender journey. It seems that there is nothing a patient can disclose—no way a patient can melt down or act out—that will draw his or her trans identity into serious question. Meanwhile, gender clinicians will applaud themselves for their open-mindedness in seeing through the ravings of a patient undergoing a serious mental health crisis to affirm his “authentic” gender identity.

The team present three cases they describe as “unique,” “nuanced,” and “intricate,” and which I would describe as fraught, troubling, and eye-popping. I’m going to focus on the first one, the case of a “bigender individual” that the clinicians will variously refer to as Steve, Jackie, or “Steve and Jackie,” as though two distinct personas inhabited a single body.