Saturday 15 January 2022

Doctors as Gatekeepers

Let me open this first post of 2022 by wishing all of you a very happy and productive New Year, and let me also hope that COVID-19, in whichever variant, doesn't interfere too much with your plans and your lifestyle.

I came across a cartoon this week on my Facebook feed*. It was drawn by Sophie Labelle at Serious Trans Vibes. She also has a Facebook feed called Assigned Male Comics. Some of her comics have been anthologised into printed volumes which are available from her website store in both English and French.

According to the Wikipedia page, the comics have been produced since 2014, and have received positive reviews from critics. Certainly she seems to attract very positive and supportive comments on Facebook, although she has also occasionally been the target of hate. From my perspective, the medium of comics is a very effective way of communicating transgender topics, and I've written about this before, here and here.

Here's the cartoon which caught my eye*. I hadn't come across any of Labelle's work before. I did not recognise the character depicted (it turns out to be one of Labelle's main characters, a young trans-girl called Stephie).

As of today, 15th January 2022, this cartoon has had over 6,700 likes, 172 comments, and 1,700 shares, although these numbers seem to be par for the course for Labelle's cartoons on Facebook.

But what troubled me about it was the implication that that doctors are deliberately obstructive to trans people; deliberately causing them to experience "unbearable pain or intense suffering"; and deliberately inflicting "torture" upon them. This view struck me as unfair and I wanted to explore it further.

Being both a trans person myself, and a doctor, I'm aware of the tension that exists between the two groups. I'm aware (of course) of the frustration that exists from trans people who cannot get doctors to listen to them, believe them, or treat them. And I'm aware (of course) of the antics which some trans people sometimes resort to, such as lying or manipulation, to try to get their way. Others resort to hormones they buy online, or travel overseas to get surgery.

And I want to explain why I think "gatekeeper" is very much the wrong metaphor for what doctors are doing.

There is definitely a problem

Before I go further, I want to state that there is definitely a problem in the medical treatment of transgender people. I am, in my professional and online lives, trying to help to put it right, and I have discussed this matter before on this blog, for example here.

I wrote a long comment on Labelle's page, attempting to explain a more balanced view. She deleted it, and posted this:
Labelle: got a few truscums who wrote 10 pages long comments on how gatekeeping is essential to be truly trans, I got to delete their comments before anyone saw them, as a morning treat! I hope they didn't save their essays anywhere and they're lost forever.
I had no idea what a truscum is, although it's obviously intended to be an insult. You can find a discussion of its meaning here on Wikipedia. From what I have read, that description doesn't apply to me.

This exchange was not the most heartening opening to a discussion I've ever had. I contacted Sophie Labelle again for her comments, and she blocked me. But I nonetheless thought it was worth exploring the two aspects of it: why do (some) trans people feel that they are being tortured by doctors, and what could actually be going on from the doctors' point of view? And, most pertinently, can anything be done to fix it?

Why is it so hard to get good transgender medical care?

I want to begin this section by pointing out that I believe most doctors genuinely want to help transgender people, and that good gender treatment is fully in accordance with good medical practice. But there are several obstacles to achieving this, some larger than others.

Road ahead closed
First, most doctors have very little or no training in gender treatment. That means that few doctors have personal experience to draw upon. In addition, guidance from professional bodies is extremely sparse. When I was a medical student, in the last century, gender identity problems were not taught at all, though we did learn about intersex conditions in paediatrics. In endocrinology, we learned about people with hormone disorders: too much of this, or too little of that, and how to help, but none of this was in the context of people who want hormones to help with their gender.

Second, many (but not all) doctors are commonly faced with patients asking for (even demanding) treatments which could be potentially harmful. Strong painkillers are a great example, and I've seen patients who have resorted to ingenious methods to circumvent the system to obtain them. We've all been bitten, sometimes very hard, by such patients, and therefore many of us are understandably suspicious of people who don't seem genuine.

Put another way, if you are lying to your doctor, there is a very good chance that your doctor knows or suspects that, and this is likely to erode their sympathy and work against getting their cooperation. There is often a distrustful undertone to the relationship between the doctor and the transgender patient, where neither of them feels that the other is being completely open or completely helpful. The whole purpose of this post is to try to improve that situation.

Third, there is a very good rule of medicine: first, do no harm. This advice is so old and venerable that people think it was written by Hippocrates. (It wasn’t). But the meaning of the statement is clear: before you give a treatment you hope will help, you need to really make sure it isn’t going to make things worse. It encapsulates a theme of being cautious in the practice of medicine, which in general is a good thing (I believe). And its core is the patient’s wellbeing, which is paramount. If you are asking for a treatment which your doctor thinks may harm you, they are very unlikely to comply.

No doctor wants headlines like this.
Fourth, there is little good science in the field of gender treatment. What good science there is is drowned amid flag-waving, virtue-signalling, politics and wishful thinking. See my post here for a detailed discussion of these issues. This is especially true for gender treatment in children.

Fifth, those few doctors who have courageously taken on the treatment of transgender people sometimes run into serious professional trouble, threatening their career or livelihood.
Dr Helen Webberley (whom I interviewed here) has been treating thousands of transgender patients (including children) for some years, but has got into some serious hot water with medical authorities in the UK. (As I write, Webberley is still under suspension from practising as a doctor, and her tribunal is ongoing).

This sort of thing acts as a powerful disincentive to doctors to advocate for transgender people or treat them. Those doctors who are interested in training in gender issues will be looking at Webberley's case, and some will decide that the risk of getting into trouble is just too great. 

All of these things make it very difficult for doctors to effectively treat transgender patients.

The fictional case of "Bob"

I've created this fictional scenario to illustrate how an ordinary family doctor, without any training in gender treatments, might approach a consultation with a late-transitioning person. I'm not trying to suggest every transgender patient presents like this. I'm not trying to suggest every doctor would feel the same (and in particular, I would not). But hopefully this scenario will illustrate some potential ways of medical thinking.

Imagine you are that ordinary family doctor, and a patient comes to see you. You have known Bob and his family for 10 years. He is 52. He likes golf and fishing. He was a bank manager until last year, when he lost his job. Since then he has put on a lot of weight and begun to drink more heavily.

Bob tells you he is transgender. He is actually a woman inside, something he has felt for his whole life, but kept hidden from everyone, including his wife. He has been cross-dressing in secret for many years. But now he feels he cannot remain hidden any more, and wants to transition. He wants hormones. He wants surgery. He wants a legal name change.

Burdened: Bob
How do you react? You’ve been Bob’s doctor for years, but he has never mentioned this before. Nothing about him seems remotely feminine.

From one perspective, the story is true. Bobbie could have kept her feelings and behaviour hidden successfully for years, but could carry the burden no longer. This is her chance to be true to herself; to finally become a woman. You look up the referral pathway to the nearest gender clinic, which has a waiting list of two years. Bobbie says she can’t wait that long and wants to travel to Thailand for surgery. She asks you to prescribe female hormones for her, but you are not familiar with these treatments, their doses, or their side-effects. You really want to help Bobbie, and you tell her you will try talking to some colleagues for advice, and you will do what you can, but from Bobbie’s perspective, what you are offering is not enough, and far too slow.

Are you acting as a “gatekeeper” here? I argue not, though Bobbie might feel that you are. Who is right?

From another perspective, Bob’s story doesn’t ring true for you. Bob has always looked and acted like a man’s man: coaching the football team, golf, fishing, powerful cars. Losing his job hit him really hard. He is probably clinically depressed. He is certainly drinking too much, and you suspect his marriage is in trouble. He certainly isn’t the first middle-class, middle-aged guy who has had an unexpected mid-life crisis, even if most of them buy a motorbike or get a tattoo. You think that it would be better for Bob to sort himself out: cut down the drinking, get another job, lose a bit of weight, take more care of himself. You offer him antidepressants and recommend exercise. You tell him that if he still feels the same once those other things are sorted out, you will help him with his request to change sex, but you think in a year or so Bob’s feelings could well have changed and he might feel very differently.

Are you acting as a “gatekeeper” here? Maybe yes (Bob would certainly think so), but are you a bad doctor for doing so? For listening to your patient, making the very best, compassionate, objective assessment of what you think is really wrong, and trying to put it right? I would certainly argue no.

Aye, there's the rub!

And that's where the scissor-point is. Bob's story is fictional, of course, but there is enough truth to it that many elements are recognisable. A doctor, with either perspective of dealing with Bob, is practising good medicine. They are not being a bastard. They are not being cruel. They are not, in any way, deliberately attempting to hurt Bob or cause him distress. They are not torturing Bob! And they are not acting from a perspective that "gatekeeping is essential to be truly trans".

No way, sucka!
The image of the doctor as gatekeeper requires that there is this wondrous place, filled with bountiful hormones and surgery and unlimited gender treatments, but there's a huge steel door, and like a big mean bouncer, your doctor is looking you up and down and saying in a gravelly voice: Yer name's not down, yer not coming in.

But no such bounty exists! From a doctor's perspective, the official pathways are swamped and waiting lists are long. Some transgender people have other issues: depression, drug and alcohol use, self-harm, which can complicate the picture. (If you treat Bob’s depression, will his desire to transition go away?) Some transgender people point to gender as their one biggest problem, and play down other concerns, even though they seem important from the doctor's viewpoint. Some transgender people seem to have unrealistic expectations of how rosy their lives will be after treatment, even though this isn’t necessarily what happens. And some people change their minds about what’s best for them, as their lives unfold.

I'm not saying that trans people who are trying to get treatment are not suffering. I am not trying to suggest they should just suck it up and forget the whole thing. Instead I am trying to point out that what doctors do is not deliberate cruelty. The situation involving children is even more fraught. Gender services for children are even fewer than for adults, and a child who is growing rapidly creates even more pressure in an already pressured situation.

So what's the solution?

The solutions are clear, but none of them is easy. First we need good science to inform medical practice. That, in itself, is difficult, slow and expensive. As I've written here, if your science produces conclusions which some transgender people find unpalatable, you are likely to face powerful negative repercussions. That in turn provides powerful disincentives to scholars to pursue the science around transgenderism.

Second, we need better training for doctors in the treatment of gender conditions. The good news is that there is some evidence that this is starting to happen, although obviously it will take a while to work through the system.

Third, we need clear professional guidance from professional bodies to existing doctors, about treatment regimes, referral pathways, and so on. Again, this is happening, with organisations such as WPATH setting out standards of care (currently brewing up their 8th edition) for transgender people worldwide.

Fourth, we need better investment and funding for those systems which currently exist, to match the increasing demand for their services, cut waiting lists, and improve access to treatment. For these outcomes, you need to lobby your politicians, not your doctors.

Meanwhile, transgender people, and the doctors looking after them, will struggle to make anything successful happen with what already exists out there.

How can I get the best out of my doctor?

The first thing to say is that doctors are people, which means there are some who are brilliant, some who are dreadful (sadly I've met some of them), and most of the rest are perfectly OK in the middle somewhere. Most of us went into medicine because we actually want to help people, after all. We are also aware that the power-balance in the doctor-patient relationship very much favours the doctor. While medical paternalism is still (unfortunately) a thing, the old notion that "doctor knows best" is obsolete, and practised only by a few, aging doctors.

But if you understand how your doctor is thinking, it is likely to result in a better outcome all round. You will be able to reassure them and defuse some of their reluctance. You will be able to put forward your goals in a way which seem to be in accordance with good medical practice, not against it.

It doesn't have to be a conflict.
If you happen to run into a dreadful doctor, get another doctor! If your doctor is uncaring, brusque, unsympathetic, or otherwise unsuitable, vote with your feet. Change to another doctor in the practice, or change to another practice entirely. There is likely to be a social media page for trans people in your area. Ask around for recommendations about a supportive doctor near you.

If your doctor seems willing to help, but unsure what to do, point them to the WPATH website, which is positively bursting with resources to help: medical guidance, standards of care, a comprehensive reading list, a search facility for colleagues and experts around the world. If they really want to talk to an actual transgender doctor, I'm happy for them to contact me by email.

Try to work with your doctor, not against them. Try not to take it as a personal attack if they don't fall over themselves to do whatever you ask. It's fine to negotiate, with statements like "I know that if I start with the higher dose, I might have more side-effects, but I'm willing to accept that risk for myself, and I will cut down the dose if I start to run into problems". Most doctors will respond very well to this approach, and many doctors like it if you've done your homework first: "I know I will have to keep an eye on my blood pressure and my blood sugar too, but I've been losing weight and keeping fit".

Plain honesty is likely to work very positively. "Look, I know it wasn't very smart, but I'm desperate, and I've been taking these hormones I got from the Internet. I brought you the box so you can take a look at them. They don't seem to be working very well. I really want to be on something safer and more effective".

Manipulation, lies ("Oh no, doctor, I would never take anything that I bought online") and subtle threats ("If you don't prescribe these for me, I'm going to start getting them online anyway, so you might as well") are likely to make things very rocky.

The hardest part (understandably) is to be patient with your doctor if they seem too slow. You may well be that doctor's first ever transgender patient. Your interaction with them will likely colour all future interactions with trans patients. Most doctors (as I've said before) will be willing to work together with you toward you meeting your goals, which will be rewarding for you both, and will likely make things easier for the next trans person that doctor has to treat.

The situation is changing. I know it's too slow for many people, but it's going to be better. Meanwhile, let's all try to understand one another a little better.


* I believe that my sharing of this image on this page consitutes Fair Use. The original cartoon was published on a public forum (Facebook), where it has been viewed many thousands of times. I have not changed or altered the image in any way. I have attributed the artist, and added links to her Facebook stream, her website, and her Wikipedia page. I have not attacked the artist or the image, but used it to illustrate a discussion point which is very strongly in the interests of the trans community--in other words, my use is in alignment with the implied original purpose of the image. I do not earn money or other reward for this blog. The image has already been shared over 1800 times without apparent objection from the artist, which indicates implied permission for its being shared online.