Excellence in Trans Healthcare

So I think that one of the biggest forms of uncertainty that has just carried through over the last 70 years is really that medical providers are not usually trained to work with gender, right. They’re trained to work with illness and disease. And so that way of thinking about what their job is supposed to be does not map easily onto working with trans people. And so I think that just creates a lot of uncertainty for them. And it’s not the uncertainty of how do I administer hormones, for example, instead, it’s more like, how do I make sense of this person in front of me? What happens when I feel like something’s not quite right? So they talk a lot about gut instinct and like flags and asking them to explain a little bit more about what they mean when they say that is when they start having trouble. So I think a lot of the ways of understanding trans people has carried through and so have their own certainties. And I think sometimes that’s hard to imagine because doctors have been working with trans people for so long. Now.

They weren’t given good therapy that they thought by just getting the right hormones, that all their problems and depression would lift, you know, bad care, breeds regrets. But actually if the starting point was, oh, you trans, how can we help? Uh, uh, uh, we talk about that phrase all the time. How difficult is it just to ask them, what do they know? How can we help, what you’re hoping to achieve? What do you need from us to be able to achieve that? It would just be a reframing, but society’s acceptance that there are just happen to be some people that are wired it’s slightly differently. And, uh, yeah, if you’re not trans, you’ll never understand it. So don’t try to,

We’ve had a bad narrative by Hollywood and by the media about trans people, if the medical model of care was flawed to start with, even I’ve bought into that model, that even, I believe that there was a hierarchy of transness that we needed to meet before we could transition. It’s only with the privilege of working at Gender GP and in my own transition that I’ve learned otherwise. But the truth of the matter is you as a doctor, unconsciously have bought into that narrative and have bought into that model of care and that we need to go back to the 1950s. And, you know, if, if we could have a back to the future, you know, if we could go and slap Harry Benjamin around the chops and say, no, you’re wrong, Harry, this is what we know about trans. Then we may have been in a different position now. I don’t know what you think to that Stef.

And these were the red flags. And so there was an endless discussion about, we cannot allow this 12 year old to start puberty. I ego to the endocrinologist until we’ve sorted out this mental health stuff. The, you know, what if they got unreal expectations about, you know, be getting pregnant, um, they’re not going to therapy. And there’s the, was this big tug. And, you know, I’m a physician. And I was just thinking, this kid wants to start puberty. You know, maybe when got that over and done with then maybe there would be some space for some therapeutic work around talking and the journey ahead of them and their life ahead of them. And actually checking the understanding as to whether this person who hasn’t got a uterus would be able to carry a child or, or not. Maybe that’s a discussion that does need to be had certainly. But why is that something that’s going to make this person have treatment withheld from them? And there was a big endocrine psychology battle going on, uh, with that fictitious case, which is why we were discussing it, of course. But, um, it was really interesting.

And I think it came from, I think it came from your classic kind of deplorable eugenics way of thinking that trans people are. So the scare quote, like unfit and unworthy, and they will, you know, tarnish any future generations that the best thing possible is to ensure that they just never have children. Um, and so it is interesting to think about how that is changing right now, where, um, like people starting hormones have convers, like they have conversations about fertility and, you know, like freezing their eggs or their, you know, sperm donations. It’s interesting to think about the role of trans people in the imagination of providers and thinking about like, I, you know, social fitness, um, and who’s worthy to raise. So

You had a mental illness. I, you know, it just follows you right down the line. The parents do not want the childs getting a diagnosis of autism because that label will follow them down the line. There’s lots of areas in this country, but who benefits? And the psychiatrist benefits, he gets, you know, $500 or 500 pounds to sit there and tell you what you already know about yourself and endocrinologists, you know, you’ll pay them to just stay there, say the bleeding obvious. That’s kinda how I experience it, so to speak. But, but then I’m bloody minded as well. I have to say,

Right? And so those small, but significant logical leaps, I think, I think that that plays into the concerns of risk. And I think that also feeds further the idea that some providers and I don’t, you know, this is clearly not all providers, but some providers who then feel compelled to gate, keep to protect trans people from themselves. And I think we can think of many examples of lots of other groups, of people where like, that just never works out. Right? You, you don’t protect people from themselves. Um, especially if you’re not a part of that group,

And if it’s high, you might have had a heart attack, but the levels are different for male and female levels. And I wanna know if I’ve got a trans woman who, who swapped her hormones really early on like age 13, 14 when, when it should happen, I believe, and this a attack’s now happening at 60, which enzymes should I be using? And these are really important questions and research ideas for the future. But it seems to me that we’re so far away from that because we’re still trying to prove that it’s okay to treat trans people with hormones. And it exasperates me. We’ve got some really, really important medical questions to ask, and it’s not, is it okay to treat a trans person and switch their hormones?

It almost sounded like a cognitive shift of having to think about what assumptions might I be making about this patient. And then that started translating over to their care with other patients as well. Right? So it almost sounds like for some providers who have humility, um, that they can lean into that and it translates to, to their patient care with other people. And, you know, I, I think for the therapist that I spoke with, a lot of them really detest the gate keeping, and it’s not a part of the orientation of therapies to prevent someone from doing what they need. And so they talked a lot about how they found workarounds, like strategic workarounds to fulfil whatever thing they needed to fulfill, but to try to work with their patients in ways that align with their therapeutic values. So I do see those as moments, those pockets of resistance and strategizing, and also like a lot of deep self-reflection about who they are and who like how they want to be in, in their medical practice or their therapy.