An invitation to responsibility for clinicians

Re-envisioning care for minors with gender dysphoria

Photo by Joseph Barrientos on Unsplash

The science seems pretty clear to me that gender affirming medical care—especially for minors and young adults—over-promised what it could deliver. Yet, I do not believe that science alone will lead us to a new vision of what good care might look like. The question of what good care might be isn’t just a clash about what the science says; it is a clash about values. Whether or not we choose to allow minors to medicalize is dependent on which values we as a culture choose to privilege. While the scientific process can help us better understand the short- and longterm ramifications of gender affirming medical practices, ultimately science does not tell us what to do, only what is and is not possible.

When clinicians approach the question of whether to medicalize minors from a values lens, rather than a scientific one, the consideration is less about risks and benefits, and more about beliefs about what makes life meaningful. Is the value of client autonomy in healthcare more or less important than the value of evidence-informed care? Is emphasizing a minor’s right to regret over an adolescent’s right to a natural puberty more or less significant? Whose experiences do we privilege? Those who say via self-report that gender affirming medical practices saved their life? Or those who say that the very same practices devastated them beyond repair? Should we make room for both experiences? Or is one more salient than the other? Is subjective experience more important than objective measures of wellbeing? Is short term euphoria worth the price of longterm health? What do we do when conflicting accounts co-exist in an ongoing battle for the hearts and minds of the general public?

These are not questions that science alone can answer. They are philosophical inquiries, about the meaning of values like choice, freedom, truth, and viewpoint diversity. Even the same value can take on different meanings depending on the frame within which it exists. For some, freedom means giving people the capability to alter their bodies and create new identities—even identity categories that have not historically existed in the law (e.g. nonbinary). For others, freedom means allowing a child to grow up with their body intact, so that they can make their own informed decisions as adults.

One segment of society may value the choice of bodily autonomy as a sacrosanct right, while yet another may see gatekeeping of invasive medical procedures as necessary safeguarding to protect the vulnerable.

Nonbinary people, or at least some who claim that label, may seek to undo the gender binary entirely—to demolish the very concept of gender roles and expectations. At the same time, others might point out that a nonbinary category reinforces gender stereotypes rather than dismantling them. While one group might believe a nonbinary identity is a pathway to authenticity, another group might frame the very same identity as the ultimate individualistic indulgence.

Science cannot tell us whether any of these interpretations are good or bad; it can only study the individual and social impacts of these cultural practices, and offer up hypotheses to explain their ramifications. What we do with the stories we generate from these hypotheses is a question of values, not data.

When I was 23 and faced with a future that seemed bleak and filled with despair, I chose hope over despair, and I reached for the best story available to me. The story that carried with it hope for a better future, was the story of being a man in a woman’s body, just waiting to break out of my shackles to become more authentically me. It was a story that offered a clear path, a destination, and a possibility of happiness. An alternative story I also received was one that said that I was mentally ill, that my depression was in my DNA, and it would follow me all my life unless I remained medicated. Even then, happiness was not guaranteed. Unsurprisingly, that story was less appealing — it offered no clear solutions, no defined path, no promise of sustained happiness. What story would you choose when faced with such options?

In retrospect, I wish I was offered a third story. Perhaps a story of struggle and persistence, a story that promised resilience and strength, love and adventure. I wish I was offered a vision that included seeing myself as capable and strong, rather than weak, broken and unstable. But I wasn’t offered that story—and I wasn’t imaginative enough to generate that story myself. Not then. Now, over 20 years later, that is the story that feels more true. I only sacrificed my fertility, my breasts, my identity, and many a relationship to attain it — a small price to pay I suppose.

I can forgive clinicians for not knowing better 10, 15, 20 years ago. Ignorance is not an excuse for incompetence, but I understand that healthcare is often an imperfect endeavour. Healthcare is filled with stories of hypothesizing, experimentation and risk-taking. When the risks work out we call it genius. When they don’t, we call it malpractice or negligence. The harms that come from not knowing better is an unavoidable consequence of clinical work—every clinician must wrestle with this truth.

None of us are always right; we can not know everything about every subject or client that comes to see us. But perhaps we can minimize harm by putting aside hubris and holding our hypotheses lightly. We might even consider listening to those who hold different viewpoints from our own—and allow ourselves to learn something from those other perspectives. But learning from those who are different, from those we might not even like, that is a difficult task. It requires moving beyond our own needs and wants, our own fragile egos. It requires prostrating ourselves before the gods of uncertainty.

In our culture we do not easily tolerate people changing their minds. We call it inconsistency, or worse, hypocrisy. We hold up outdated ideas as if they are gotcha moments from the past instead of potential demonstrations of deepening understanding. I think this is unfortunate. I admire much more the practitioner who recognizes the limits of their own knowing and remains open to course-correct when the evidence demands it.

But changing course when you are part of a larger system that has enabled you, is hard. It can feel like trying to redirect the Titanic away from an oncoming iceberg when you’ve already gotten too close. The gender affirming care ship may have seemed swanky at one time, but its hull is now damaged, its passengers and crew are jumping ship.

We need a new vision now—one that is inclusive of different experiences while also being grounded in material reality. As we build a new ship, we will need to listen to and include the voices of those who think differently from us. This might include those who practiced gender affirming care on minors, and those who did not. It might also include those who feel they have benefited from gender affirming care as well as those who feel strongly otherwise. It will require mediators and healers of all stripes to navigate new pathways forward. That is true inclusion. We need all hands on deck.