By Kathy Mandigo
I am packing up my stuff to move, and I came across a folder of work-related papers. One item was a card I had forgotten I had, but as soon as I opened it, I remembered it and the sender. It was a card of thanks from a transgendered patient, a lesbian who transitioned to a man, expressing appreciation for my help in her* journey to become the man she felt she was.
*(While I used to accede to my patients’ chosen pronouns, I now use the biologically appropriate one.)
I saw this patient at a youth clinic (patients under 26), and she was usually accompanied by her girlfriend. She had been seen and assessed and started on treatment at the Gender Dysphoria Clinic that ran at the time in a local hospital. I initiated nothing, merely administered the testosterone injections they prescribed.
I watched my patient change: she gained weight and muscle, developed a lower voice, sprouted facial hair, and described increasing sex drive and aggressiveness. I remember feeling comfortable that this patient seemed very grounded and confident, and I did not feel manipulated in our interactions, which helped me feel comfortable to administer the injections.
I saw this patient in the mid or late 1990’s, I don’t exactly remember, and as I recall, she was the first transgendered patient I had seen. I was less than ten years into medical practice and hadn’t been taught anything about transgenderism in medical school. I was young and naive and trusted science. There was no science about transgenderism. What was I to do?
With the growing criticism of medicine and physicians as paternalistic, we were encouraged to listen better to our patients, to their expressed realities. Although we did not take the Hippocratic oath in our medical school, we did still attend to the tenet of first do no harm, but I had no idea how to weigh the risks and benefits of attempts at gender transition. I didn’t have a personal opinion then about transgenderism, and professionally I felt an obligation to try to meet my patients where they were, rather than where I was. I wasn’t willing to diagnose transgenderism, but if the team of proclaimed professionals at the Gender Dysphoria Clinic had made such an assessment, I was willing to be the family doctor who provided follow-up.
A few years later, a pilot project clinic was opened within one of the community health centres in our city, a clinic specifically for queer patients. We staffed our clinic with as many queer providers as we could find. We expected a flood of queer patients alienated from the traditional medical system; those whom we actually saw were mostly alienated transgender patients, who either had not been accepted for gender transition by the Gender Dysphoria Clinic (often for psychological reasons) or were unable to tolerate the long assessment process of the Gender Dysphoria Clinic (again, often for psychological reasons).
As I recall, all of these patients were men wanting to transition to being women, and, as I recall, all of them struck me as psychologically unwell, as manifested in their behaviours. I remember thinking that there was an atmosphere of coercion among the staff in which it was uncool to question the validity of the patients’ desires and expressed gender identity. Any psychological disturbance was often attributed to the patient’s suffering of living their life in the “wrong” gender.
I remember often feeling that these patients tried to intimidate me into giving them what they wanted, that they often assumed outraged insult if I asked questions (how dare I enquire, presumably doubting them), that if I did not give them what they wanted they exploded into enraged diatribes and stormed off. I felt very uncomfortable with them and it was challenging to try to do my job and not react to their anger.
The pilot project did not last long, as there were few patients, other than this handful of disaffected transgendered patients. It may have been that, because the clinic operated on Monday afternoons, more well-adjusted patients were likely working and unable to access the clinic. It may have been that most queer patients by that time felt comfortable accessing the health care they wanted. Those questions were never asked to sort out whether it was lack of accessibility or lack of need.
Over the next years, I did not see many transgendered patients, until recently, and with most of them disproportionately appearing among the demographic of mentally ill and addicted in our city.
One patient came to my private office, a lesbian who was transitioning to a male, under the care of a gender specialist of some sort. (The Gender Dysphoria Clinic had ended, I wasn’t clear why. I believe this was effected under the guise of rhetoric that all doctors ought to provide this care rather than it being relegated to a specialty clinic, but I expect there were other politics at play. Disturbingly, what has been opened is a transgender clinic within the provincial children’s hospital.)
She came to my office telling me that she had heard I was a great doctor and that I specialized in transgender issues.
I immediately felt I was being manipulated with a big buttering-up job, and I said this was not true, I was neither a great doctor nor a transgender specialist. My guard was up. I expected this patient read me as a dyke, though I never disclosed, and over subsequent visits, this patient continued to try to be my pal, with an overly-friendly us-two-dykes demeanour, like we were butchly comrades, as though she was forgetting that she believed she was a he.
Over time, I discovered the patient had been withholding unflattering information from me that would have sped up diagnoses of her other issues. I increasingly felt she was attempting to manipulate me with her excessively friendly behaviour, and then pressure me with her sense of what my obligations were (e.g. that I should provide a letter of support for her to have the gender on her birth certificate changed, when in fact this was her specialist’s responsibility, as the diagnosing physician, a responsibility that he had fulfilled, despite the patient’s claims and demands to me).
I tried to be professional, to mind the boundaries (e.g. not provide personal information, not collude in the play of friendship), and I administered the testosterone injections her specialist had prescribed, until the patient’s girlfriend felt comfortable to take over. I held this ground, and eventually the patient tired of me, undoubtedly disappointed and disparaging, and left my practice.
Another patient I saw in my other, public health work, was a man transitioning to a female. What I was told by a nurse of the patient’s story, of what clinics he had attended and who his doctors were, was all over the map, which made me suspicious about what the “facts” were and that I had to verify anything he said.
When I saw him, he began by being all girl-friend-y with me, like we were two girls together in this crazy world, behaviour I assumed he had seen and adopted as how women get what they want (had he ever read me wrong! he was mimicking behaviour without having the years of lived experience by which a women learns, if so inclined, when to use that tactic).
As I asked questions about his health background, he became uncomfortable that my questions were revealing inconsistencies in his story (suggesting to me psychological problems), and he got angry and leaned forward into my personal space and flashed me that “you fucking cunt” look.
All women know that look. This was the same look I remembered getting from the patients I saw at the pilot project clinic, but I didn’t know then what to call it, what it was. Now, after so many more years of life experience, I knew exactly what it was: it is a look that men give women to dismiss and devalue and intimidate; it is not a look that women give women (they dismiss and devalue and intimidate in other ways, often by being passive-aggressively haughty).
I was better able, after the years in practice, to hold my ground, and I calmly told him that his angry tone and demeanour were making me uncomfortable and he had to calm down or the visit would be over. He denied being angry, but continued to have the angry tone of voice and body language that goes with that look, part of the package of male power tactics.
I stood my ground and repeated that he was making me uncomfortable. Eventually he settled, I gave him the (non-gender-related) prescription he had come for, and we terminated the visit. I saw him a second time some weeks later, and he did not flare into anger. Whether he was having a better day or had learned to camouflage and control himself better, I do not know.
These experiences, of seeing more men wanting to transition than women, of seeing almost all of the transitioning patients behave in stereotypical gendered ways (their biological gender behaviours flashing through their assumed gendered behaviours) and out of these behaviours try to manipulate me (rather than being able to discuss the situation openly and honestly), seeing more of these transitioning men settling among the mentally unwell in the most disenfranchised neighbourhood, and especially seeing the transgender men continue to exhibit male aggressive behaviours, has convinced me that most, if not all, transgender patients are not in the wrong body but have mental health problems, problems they believe can be fixed if they get in the right body.
At the beginning of my years of practice, with my youth and inexperience, I thought I had an obligation to follow the patient. Now I believe that I failed these patients, and that I have a superseding obligation to tell the truth to my patients. I regret every testosterone injection I gave, every estrogen prescription I refilled, and every time I colluded with my patients in their gender delusion. I regret not speaking up to my colleagues and to my patients, instead giving in to the coercion I felt to go along rather than dare to question. I regret not having had the courage to ask questions to get to the story beneath the gender dysphoria story, to find out why my patients had ever been made to feel there was anything wrong with them in the first place. I want to tell the women that we need them as women, and especially as lesbians; I want to tell the men that no amount of medicalization will make them women. Women may have an easier time of masquerading as men, but as long as every man has within him the “you fucking cunt” look, no man can ever masquerade as a women.
That first patient’s composure stands out from my subsequent experiences with transgender patients. Surely it helped her navigate the Gender Dysphoria Clinic. Was she truly of a different nature, or had she, with her relative youth, not accumulated distorting grievances? After finding that card, I tried to look her up. I wanted to ask if she was still grateful for transitioning, if she was still as happy to be living her life as the man she believed she was, if she still believed she was a man. I could not find her, at least not under his name.
Kathy Mandigo is a general physician in Vancouver who has been in medicine for over thirty years. She has a Masters degree in Epidemiology, and has worked in public health and private practice, at the Canadian HIV Network and the BC Centre for Excellence in HIV/AIDS, and Health Canada.