What Does It Mean To Act With Compassion Toward Someone Seeking Out Medical Treatment?

Once more unto the breach with this whole gender dysphoria thing

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I’m probably going to soon take a long break from writing about anything gender-dysphoria-related, for a variety of reasons I’ll explain if I do end up making that decision. And I definitely didn’t intend to do two consecutive free Singal-Mindeds on this subject. But an article in this week’s New York Times Sunday Magazine by Daniel Bergner, who is an excellent reporter — you should check out his book The Other Side of Desire: Four Journeys into the Far Realms of Lust and Longing — really deserves a bit of comment and analysis.

“The Struggles of Rejecting the Gender Binary” goes the headline. The subhead: “Not everyone identifies as male or female. This is what it’s like to be nonbinary in a world that wants to box you in.” The article is mostly about nonbinary young people seeking out hormones or surgery.

When I read an article like this, I’m doing so from a very specific place. I’ve been lucky enough to spend dozens of hours interviewing, via phone and email, some of the top gender-identity clinicians in the country. They’ve walked me through what they think the diagnostic process should look like, ideally, before someone with gender dysphoria goes on hormones or has surgery, the former of which often has permanent effects and the latter of which always does.

As I explained in my long, almost year-old (!) article in The Atlantic, which contains more quotes and insights from these conversations than anything else I’ve written, many clinicians believe exploration is key to good outcomes. If a young natally male person says to a psychologist “I’m not really a boy — I’m a girl,” a good clinician will help them explore, in a compassionate way, what it means to them to be a girl. There are situations in which “I’m a girl” translates, at root, to social problems at school, or to other mental-health issues, or to trauma, or to a reaction to being forced into certain gender-role boxes. There are also situations in which “I’m a girl” means the patient has severe, persistent gender dysphoria that will likely not go away if they are denied access to transition resources.

I’m of course oversimplifying this a little — things are often not quite so clear-cut, and nature and nurture and culture and everything else mix in complicated ways. But the sense I got from my interviews is that competent clinicians take different approaches to different kids. There are some instances in which it’s pretty clear that all that’s going on is gender dysphoria, and there aren’t too many complicating factors that might cause a clinician to urge caution and more deliberation and discussion prior to proceeding with medical interventions — Scott Padberg, a Portland-area teenager in my article who was a patient of the leading clinician Laura Edwards-Leeper, is one such example. In other cases, things end up being more complicated: Delta, another teen from my article who was seen by Edwards-Leeper, fit more in that category and ended up realizing she wasn’t, in fact, trans. The caution urged by Edwards-Leeper and Delta’s own mom spared her what would have been unnecessary and potentially harmful medical treatments.

This is the ideal case: a compassionate, caring clinician who understands that some people really do need to go on hormones, and will suffer if they can’t, but that it’s a complicated, likely permanent medical decision that requires serious deliberation and exploration. Unfortunately — and this is something I’ve become increasingly aware of — it appears there are only a tiny handful of clinicians in the country capable of delivering this level of care. Because gender dysphoria is such a difficult, fraught subject, and so few clinicians have serious experience or training in treating it, something of a Wild West may be developing when it comes to clinical care for this population, and the Sunday Times article provides a prime example of what that looks like.

You should read the whole thing, but I’m going to focus on Salem, a nonbinary 20-year-old who is one of the main subjects of Bergner’s piece, and who lives in rural North Carolina with their family (like many nonbinary individuals, Salem uses the gender-neutral pronoun they). Salem has not had an easy life — they have a long history of various struggles, including mental-health problems, social ostracization, and online dabbling with white nationalist communities. When we first meet them, they seem to be in the midst of a mental-health crisis — they have recently taken off all their clothes at home and scrawled TRANNY and FAGGOT on their body, and they appear to fall into a dissociative fugue right in the office of their therapist, Tate:

For the next minutes, Salem tried to criticize Tate, to lash out at her, for failing to help them enough, and Tate encouraged the effort. But quickly Salem fell mute. Body utterly still, they withdrew further and further, the glaze of their eyes clouding, until Tate felt that her client was in a state of dissociation, totally detached from their own surroundings, absent from the room, from themself, gone.

Under these circumstances, Salem has gone on hormones. It isn’t quite clear why, or what the process of making that decision looked like, other than that Salem doesn’t want to come across as quite so male-looking. They aren’t even sure they want breasts, which is exactly what happens when someone with a male body starts blocking their own male hormones and taking estrogen:

Salem felt driven to feminize their body, to lessen their constant alienation from their own anatomy — and their self-revulsion — but wasn’t at all sure what the right combination of feminine and masculine would be. Different days brought different answers. From the hormones, their breasts were buds. “I could foresee breasts bothering me,” Salem told Tate, though they believed they wanted them. “I just have to hope the hormones don’t make too big of a problem.”

Even so, Tate commented tentatively that Salem seemed more confident since starting the hormones, that Salem seemed to be making progress in accepting themself.

“While I’m presenting myself as more comfortable,” Salem mumbled, head bowed, “the feeling I have is that I hate myself.” They sometimes called themself a monster.

Why did Salem go on hormones before deciding for sure they wanted breasts? Should it concern Salem or Tate that the hormones aren’t really bringing a relief from their intense feelings of self-hatred? Did Tate — the professional clinician charged with safeguarding the well-being and buttressing the healthy decision-making of a young person with serious problems — offer any guidance as to how that decision should be made? The article doesn’t say, but the pretty clear sense it gives is that during a moment of genuine anguish, Salem just sort of wandered into this decision without knowing exactly what they were doing.

Bergner makes it clear that this sort of vagueness often suffuses cases like Salem’s, which differ from more clear-cut ones in which someone born male simply wants to present in the world as female, or vice-versa. Bergner notes that “the goal of treatment [for nonbinary people] is often unclear to the patient themself; the prevailing binary paradigm doesn’t apply. The need is to get beyond [gender], but how?” Doctors and psychiatrists who express skepticism are part of the problem: “To make the doubt and dismissal faced by nonbinary people worse, some physicians and surgeons who are committed to treating binary trans patients with hormones and surgery are wary of doing the same for the nonbinary, questioning whether the interventions are psychiatrically, and therefore medically, necessary.”

I guess it depends a lot on the nature of this questioning, no? In Salem’s case, how could a competent medical caregiver not question whether they should go on hormones? Salem isn’t even sure that they want breasts! Why would you possibly take a substance that will cause you to grow breasts if you aren’t sure you want them? I could practically hear the voices of the clinicians I have interviewed over the years screaming in my ear as I read this article. It seems like in the case of Salem (and others mentioned in the article), there was just no real exploration, no real attempt to unpack the complicated dynamics of gender, and none of the real work that, in the best cases, goes into helping someone figure out if hormones and surgery will make them feel better in the long run.

The one exception, naturally, was someone who didn’t even want her name to be used:

A New Jersey-based therapist in her 50s, who describes herself as a butch lesbian and who has worked with nearly two dozen nonbinary high school and college students, is more circumspect. She guessed that many of her assigned-female nonbinary clients would once have lived as butch or — a subcategory — stone butch lesbians. “Are we just being faddish in the wish for more and more individualized identities?” she asked. And what percentage of the nonbinary kids now coming to her will be calling themselves nonbinary 10 or 15 years in the future? “To tell you the truth, I can’t be sure.” But despite her skepticism, her sense is that something urgent is going on, that new and necessary territory is being delineated. She’s not, at base, at odds with [a nonbinary clinician mentioned elsewhere in the piece], who wonders if we will all gradually question whether “the gender binary is inherent to human experience.”

Something urgent sure as hell is going on. There are large upticks in the numbers of people, particularly young ones (nonbinary folks are mostly under 30, Bergner reports), who are experiencing such distress at being seen as male or female that they desperately want out the whole thing. As this anonymous therapist points out, though, there’s just no way to know exactly what’s at play here. And most of the people who are suffering don’t have access to a good, thoughtful, careful clinician to help them figure this stuff out — they might not even know what to look for in one. There are a million screaming sirens urging caution, and the only response, in terms of how progressives are publicly discussing this issue, is to call anyone with questions about this a bigot. (I want to reiterate that I think Bergner is an excellent reporter, but I really do question the framing of qualms on the part of medical professionals as “doubt and dismissal,” at least in cases where, as Bergner describes, the patients seeking the treatment don’t even know what they want, exactly — “the goal of treatment is often unclear to the patient themself” — but rather just have a general sense they need to do something to change their body. The Hippocratic Oath is a real thing!)

Toward the end of the story, we catch up with Salem again, months after the dissociative episode in Tate’s office. By that point, they do seem a bit happier. They feel less socially isolated, in part because they’ve found a local queer community. Months into hormones, though, they still aren’t sure they want breasts — even as those breasts are developing: “Salem’s breasts had grown. The plan was to buy a sports bra both for exercising and ‘to compress, because sometimes’ — though the hormones seemed a success on most days — ‘I’m not a fan of my breasts.’” ‘Compression’ means that, like some trans men, Salem sometimes feels uncomfortable as a result of their breasts and wants to hide them, so as to appear more masculine. So over the course of however many months, Salem decided, during what certainly seemed like a mental-health crisis, to go on hormones, then their breasts grew, and now, even if “the hormones seemed a success on most days,” on some other days they cause sufficient enough distress that Salem wants to compress them, the way natal females with gender dysphoria do — suggesting the breasts are themselves causing some level of dysphoria. Of course Salem could have simply waited to go on hormones while exploring other aspects of their identity, finding a queer community to hang out in, and so on. Exactly what a competent clinician would have recommended, I imagine. It’s unclear why someone who was already well past puberty anyway needed to go on hormones right away, when their sense of identity was in such flux.

Now, none of this means Salem shouldn’t have gone on hormones! Maybe five years from now they will be glad they made that decision. But it does mean that somewhere, at some point, someone who knows about this stuff should have asked Salem to take a deep breath and think this stuff through before making a permanent medical decision. Someone needed to be the adult in the room, not to tell Salem what to do — I do still believe in the informed consent model in which trans adults, at the end of the day, get to make their own decisions about their medical care (though do read this more skeptical piece on that subject by Carey Callahan, a detransitioner) — but to explain that actually, going on hormones is a big deal, and it’s a particularly big deal if your end goal isn’t to look like and be read as a woman.

The idea that I’m supposed to read this as a positive story (other than the part about Salem finding a queer community, which will undoubtedly improve their quality of life immensely) doesn’t make sense. The idea that, as a progressive and a science writer, I’m supposed to nod along and say that Salem is part of some sort of revolution we should be applauding and helping to spread — a revolution in which we put troubled kids with serious mental-health problems on hormones that will cause effects they aren’t sure they want — doesn’t make sense. The idea that it’s unaffirming or backward or bigoted or transphobic to say “I think the best outcome for Salem would have been a bit more exploration before embarking on a permanent medical journey they already seem to be partially regretting” doesn’t make sense.

I’m almost positive, because I’ve had conversations like this, that the anonymous clinician who didn’t want to be quoted recognized that in the present climate, her skepticism — skepticism that 15- and 17- and 20-year-olds always know exactly who they are and who they will be in 10 years, meaning the most common-sense form of skepticism imaginable — could cause harm to her professional reputation. That’s where the climate is right now, at least in progressive circles. (There are of course conservative circles where people are far too skeptical about putting young people on puberty blockers and hormones, which causes tremendous harm of its own, but it just isn’t conservatives who are dictating what mainstream coverage of this issue looks like, or how the major medical and psychological and psychiatric professional organizations handle it.)

Other clinicians are speaking up and using their names, though. Or at least they were as of when I was working on my Atlantic story. Here’s a paragraph from it:

Edwards-Leeper isn’t alone in worrying that the field is straying from its own established best practices. “Under the motivation to be supportive and to be affirming and to be nonstigmatizing, I think the pendulum has swung so far that now we’re maybe not looking as critically at the issues as we should be,” the National Center for Gender Spectrum Health’s Dianne Berg told me. Erica Anderson, the UCSF clinician [who is herself trans], expressed similar concerns: “Some of the stories we’ve heard about detransitioning, I fear, are related to people who hastily embarked on medical interventions and decided that they weren’t for them, and didn’t thoroughly vet their decision either by themselves or with professional people who could help them.”

It got edited out of the story, but including Berg, three different clinicians, all thoroughly trans supportive and professionally dedicated to getting trans youth the healthcare they need and deserve, invoked the exact same image of a pendulum. How many clinicians need to express concerns, how many detransitioners do we have to hear from, how many stories normalizing serious, hastily-embarked-upon medical procedures in complex cases do we need before we can treat this like we’d treat any other medical controversy, before we can inject it with just a little bit of compassionate common sense?

If the present trajectory continues, this is not going to end well.

Questions? Comments? Offers of bribes for me to switch subjects? I’m at singalminded@gmail.com, or on Twitter at @jessesingal. The lead image is via Esquire.