Attacks on trans people harm all of us

What I’ve learned from ten years of providing transgender health care

In Torrey Peters’ brilliant novel about transgender community and parenthood called Detransition, Baby, there’s a brief mention of a doctor who prescribes gender-affirming hormones to the protagonist. It’s a throwaway description in the book, but it has become lodged in my consciousness.

The doctor is paternalistic and a little creepy, waxing poetic about how “grateful” all of his trans patients are that he deigns to prescribe them their medications.

“Don’t be that guy,” I told myself, when I read the book. I am a doctor who provides hormones to my trans and nonbinary patients, but I don’t want to be all weird about how great that makes me. I don’t need to brag about it. I don’t need to get in on the fray. I told myself: Just do the work, quietly.

I started learning about trans health care when I started my training as a primary care doctor almost ten years ago. I thought as a general primary care doctor, I didn’t really need to focus on gender-affirming care since my patients could go to world-famous LGBTQ+ health centers. And frankly, many of them do. I live in Philadelphia, where health care is big business, and you can find an ultra-specialized doctor for anything you need.

But many people can’t access those ultra-specialized centers, even if they’re physically only a few miles away. Once I started practicing in New Jersey, I started to realize how great the need is for gender-affirming care offered by regular old primary care doctors like me. My patients who are publicly insured in New Jersey can’t see a doctor across state lines — this has nothing to do with gender care being under attack; it’s that Medicaid is state-specific — and I realized that a lot of people where I practice really, really need a queer-friendly doctor.

That’s me, it turns out. Over the last few years, gender care has become a bigger part of what I do. It wasn’t exactly intentional. I’ve just started responding to the needs I saw amongst my patients.

Nerd out with me about primary care for a moment. I trained at a hospital where primary care doctors prided themselves on doing everything: delivering babies and doing joint injections and treating HIV and putting in IUDs. I was proud to do it all, but it’s also a lot, and the range of services I provide has gotten more narrow over the last few years. (These days, no more delivering babies! Which occasionally makes me sad, because it’s so awesome.)

There are costs and benefits to the increasingly narrow scope with which most American physicians practice medicine. And in particular, when it comes to stigmatized forms of health care — abortion, LGBTQ+ care, and addiction medicine are examples that come to mind — we have a long history of segregating those services at specialized clinics.

There can be benefits to receiving care in ultra-specialized settings. Patients see health care providers who are experts in the field, and clinics focused on one type of care often provide important services like mental health care and case management. The clinic staff are used to dealing with the specific type of bureaucratic headaches that come with trying to get their specific type of care approved by insurance. For all these reasons and more, many of my patients prefer to get gender-affirming care at places like the Mazzoni Center here in Philly, or other world leaders in LGBTQ+ health like Fenway Health in Boston. Many others seek out transgender care online, from a range of excellent options like Plume or QueerDoc.

There can also be downsides to such ultra-specialization. It’s also a way that these stigmatized services are ghettoized. So some patients prefer, instead, to come to my nondescript office and get their gender-affirming hormones prescribed alongside cough medications and blood pressure pills.

That’s why it can also be good to integrate traditionally segregated types of health care into primary care. Nobody knows what is going on here! We don’t have protestors or news crews harassing our patients. It’s hard to target us because, well, I saw a one-year-old with a runny nose just before I saw a trans patient for her hormones.

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Gender-affirming care is one part of my primary care practice, but not even remotely all of it. I am a true generalist. I do the work because I believe it’s important to provide what should be an ordinary part of primary care.

And as such, I haven’t written or spoken much about it. “It’s not about me and how progressive I am,” I told myself, remembering that self-aggrandizing doctor in Detransition, Baby.

But with all the hate and fear directed at trans and queer communities these days, I’ve been thinking a lot about how I can be a better ally for my gender diverse patients and friends.

What I keep coming back to is this: Attacks on trans people harm all of us, and it’s our collective responsibility to stand up to them.

I learned about hormones in medical school, and I learned about them again in residency, and I continue to learn more about them every day in clinical practice. The biology is complex. The nuances of my patients’ needs continue to humble me. For advice, I rely on expert guidelines (particularly from UC San Francisco), and online communities of other health care providers who do this work.

As my education continues as a provider of gender-affirming hormone therapy, I’ve learned so much about gender in general — and I’ve learned about my own gender. That’s what has surprised me the most about doing this work. Gender is complex, and it’s complex for us cis people, too.

M. Gessen, the well-known expert on Russia and authoritarianism who also happens to be non-binary, has given many thoughtful interviews about gender politics and why the right is so fixated on a small population of trans people.

Here they are on the New Yorker radio hour. This argument has stayed with me since I originally listened to the interview almost two years ago, and has transformed my thinking about gender and the way I take care of my patients.

[Judith Butler] said that gender is imitation without an original, and I think that's a beautiful description …

The gender of a five year old girl and a 50 year old woman is not the same, right? We think of these things as stable and knowable, but they're not. They're actually fluid, by definition. In our lived experience, they're fluid.

Recently, I saw a non-binary patient in my clinic who was interested in getting gender-affirming top surgery, but was nervous about starting hormones. They worried, however, that the surgeon would “require” the patient to take testosterone for a certain period of time before agreeing to proceed with the surgery.

“I always thought you had to prove to the surgeon you were really trans,” the patient told me.

(It’s not true, at least with the surgeons and insurers I work with. I don’t doubt that similar policies have existed at some point; there’s a long history of gatekeeping and paternalism in gender-affirming care, like patients needing letters from psychiatrists “proving” they were truly trans before starting any kind of medical treatment.)

But also — what a rigid and unnecessarily binary framework! What if I, as a cisgender woman, had to wear high heels for a certain period of time to prove I was feminine enough to get the haircut I wanted? What if my husband had to grow a beard in order to buy a suit?

Gender is ever-changing for all of us, and the symbols we use to affirm it are always changing, too. They’re historical and cultural. My (hipper than I) Gen Z students express femininity with ultra-baggy pants, whereas this millennial lady is just dipping her toes into worlds beyond skinny jeans. Expressions of femininity in the United States are different than femininity in, say, Tanzania, where I briefly lived in my early 20s. My friends there often gently encouraged me to trade in my capris (hey – it was 2008) for long, lush wax print dresses.

My own experience of gender has changed even within the course of my own life. The way I embodied my gender in my teens is different than the way I embody it now, in my late 30s. That embodiment is about my appearance and mannerisms: I’ve changed my hair and the way I dress many, many times over the years. It’s also about a deeper identity, too. I’m a mom who’s been pregnant, given birth, and breastfed my son. I’ve settled into a professional identity as a physician, with an appropriate confidence that comes with my growing clinical experience. Both of those identities are ways that I exist as a woman, and they’re different from the way I existed as a woman at, say, age 16, or even age 25.

I’m a straight, cisgender woman who is married to a cisgender man, and in many ways I’m quite traditional. The last thing I want to do is presume to speak for the transgender experience. Obviously, that is not my goal.

But in considering the Trump administration’s attacks on transgender rights, it’s important to think about what’s underlying the agenda. It’s gender essentialism — and it’s deeply hostile to us cis people, too. It denies the reality that gender is culturally and historically fluid. It denies our freedom to explore different ways of affirming it.

We cis people affirm our gender, too — all the time! Affirmation can take the form of medical treatment — like the hormones I prescribe, or the surgeries my colleagues perform — but it can also mean the way all of us present ourselves to the world, the way we carry ourselves, and the roles we take on. Limiting it makes all of us less free.

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When the Trump administration issued an executive order in January that aims to restore “biological truth to the federal government,” I read the document with deep concern — and also confusion. It is clearly designed to foment hate and fear towards transgender people. But it also struck me as incoherent, and its legal implications as unclear.

Which is why I was so disturbed to learn, shortly after, about the halting of some gender-affirming services at New York University’s health system. NYU’s website (still!) brags that they’re a leader in transgender health care, but I was shocked at how quickly the institution rushed to comply with an order that wasn’t legally binding. (The move has to do with fear of losing federal funding for research and other projects — a not unrealistic concern, but one that is still hypothetical as courts determine the legal reach of the Trump administration’s transphobia.)

Small consolation, that the brave New York attorney general ordered institutions to comply with state non-discrimination laws and resume the services.

These are scary times. But amidst the fear and the confusion, I also see glimmers of joy.

Even in the last few weeks, I’ve had a handful of new patients come to see me to start gender-affirming hormone therapy. One young trans woman was grinning from ear-to-ear, tears in her eyes, as I clicked the button to e-prescribe her medications.

“I want to call my mom,” she said, so we did, and put her mom on speakerphone.

“I’m just so happy for my kid,” her mom said, her voice cracking. I was happy, too.