My Disservice to My Transgender Patients

By Kathy Mandigo

image  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.

Gender Hurts, Thistle Petterson

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Comments

  1. Reblogged this on Stop Trans Chauvinism.

    Liked by 1 person

  2. Trish Oliver says:

    Thank you Kathy I send you profound respect and thank you for your courage to share. Such an important account.

    Liked by 8 people

  3. Kathy’s analysis that transgenderism is a form of mental illness strikes me as being very reductive. I have no doubt that anyone who experiences transgenderist desires will also suffer severe mental injury in our current gender bound society. Injury and illness are different concepts, one arises naturally in the body as the result of infection and deterioration of bodily systems, the other is caused by outside – in this case – social forces. Our socially tight concepts of gender as a singular duality which informs our social ideas of what maketh a woman and man as different beings, does not include the lived experiences of many many people. Hence the rise of transgenderism. We can see transgenderism as a gift rather than some sort of social curse. Transgenderists challenge the tightly defined gender roles that our society currently allows in ways that nothing else can. We all owe a debt to those who have entered the arena of transgenderism which we should be ready to recognise along with any critique we may want to make of the issue itself.

    Liked by 1 person

    • Bulemic and anorexic people believe they’re fat despite all evidence to the contrary.

      There are people who call themselves “transabled” who want to remove functioning body parts so they’ll be disabled.

      Transgendered people believe they’re the opposite sex despite all evidence to the contrary and are willing to remove body parts to “prove” it.

      Yeah, that’s not mental illness.

      I can’t think of any other name for a drive to destroy one’s own body.

      There were already people challenging gender roles. They were called second-wave and radical feminists. If you had bothered listening to them instead of all that “LA LA LA LA I CAN’T HEAR YOU TERF” crap, you’d know that by now.

      Liked by 15 people

      • Yep…What if someone came along and said they feel like really they were meant to be a cat? They are a cat trapped in the body of a human. I don’t say this to diminish the confusion and pain suffered by someone struggling with gender identity. Where is the evidence that chopping off body parts and putting on a dress fixes these thoughts? This is not an ideology issue and until people stop calling it that there will be little effort to find what truly helps people cope and feel better. Calling it an illness is not meant to belittle someone.

        Liked by 4 people

    • Oh, and crossdressers. And femmey gay men. BOY GEORGE, for crying out loud. Trans activists scoff at all those people now. Of course you would.

      Liked by 7 people

    • But the whole point the author is making is that transgenderists do not challenge gender roles at all; they embrace gender roles with all their might, insisting that, if they enjoy a particular role, that means they must “really be” that sex. It is the most conservative, gender-conforming approach possible.

      The transgenderists would also like you to believe that the mental illnesses which they exhibit are the result of societal pressure, but that alone is reductive. Is it not important that the physicians who are diagnosing these individuals ensure that there is not another illness that is causing the gender dysphoria and which could be effectively treated without the dangerous and irreversible treatments currently offered to transgender individuals? Read Walt Heyer’s story of how, after destroying his health and genitals in an attempt to become a woman, he finally received the treatment he needed for the disassociative disorder which he had developed as a result of childhood trauma, and went back to living as a man. It seems that there is too much pressure on these clinicians to ignore signs of mental illness and embrace “gender identity” without applying any of the diagnostics or expertise they are trained to provide.

      Liked by 15 people

    • But they don’t — transgender people don’t “challenge the the tightly defined gender roles”. They leave the gendered boxes exactly as they are, as they merely move themselves from one box into the other. I would love to see more men who continue to recognize that they are biological males as they dress in so-called “feminine” clothes, wear so-called “feminine” makeup and take up so-called “feminine” occupations. Then they would actually be breaking up and opening up the male gender construct.

      Liked by 12 people

      • Exactly. We were closer to that in the 80s than today. The 80s was a great era in many ways in according to gender non conforming men and women. But something happened since then and gender stereotypes is reinforced harder than ever under the false impression that its progressive.

        Liked by 7 people

  4. Reblogged this on loving lily and commented:
    What a brave woman!

    Liked by 5 people

  5. Reblogged this on RaFeCaMe.

    Like

  6. Reblogged this on Jill Gertrude.

    Like

  7. I so agree with this. I think the whole transitioning concept is a shill for Big Pharma & the plastic surgery industries. You cannot change your biology or your DNA.

    Liked by 7 people

  8. Reblogged this on GenderTrender.

    Liked by 3 people

  9. From the mother of a teen who one day abruptly announced she wanted to be a boy, I thank you from the bottom of my heart for posting this honest account of your professional experience. While some girls may in fact end up happier with an eventual medical transition, it is my opinion that a great number of them have underlying issues which are the main cause of their desire to transition, rather than the trans feelings being the main cause the mental issues.

    I am just a mom, not a doctor. But I know my kid better than anyone, and I am highly skeptical of her claims that she is “really” a boy.

    Thanks again for speaking out.

    Liked by 10 people

  10. Thank you so much for speaking out!

    Liked by 2 people

  11. Reblogged this on ..

    Like

  12. Thank you Kathy for speaking out. We all know that Transgenderisim is a Mental illness and no amount of Medicine will ever turn a man into a woman. It’s very obvious that the entire trans community has mental illness issue.

    Liked by 7 people

  13. atranswidow says:

    Thank you for telling of your experiences and how your views changed as you were exposed to people who you felt were essentially trying to manipulate you to serve their own ends. It is wonderful to see real humanity and concern from the medical profession, instead of a following of guidelines and unquestioning adherence to the published protocols.

    As the ex wife of a man who essentially destroyed his family with the full help of every doctor and therapist that he saw along the way I can’t thank you enough for publishing this.

    Liked by 10 people

  14. Shared to my FB page, takes a long time for doctors to step out of the heavy hand of group think… but eventually, they will start to come around. Science is on this side… we must keep pushing…

    Liked by 2 people

  15. Brava. Thank you for sharing this with us.

    Liked by 1 person

  16. Thank you for sharing your story. I’ve worked in mental health facilities and with mentally ill populations for many years. I don’t think being transgendered is a mental illness in itself, but the compulsion to transition is a symptom of a larger underlying mental health problem. I hope that more professionals are able to question the PR tale sold to the public regarding transitioning. Society doesn’t indulge people with anorexia or BIID. I worry that no one seems to care about the long-term health consequences of transitioning. This silly fad will become a major public health crisis in 10 or 20 years.

    Liked by 5 people

  17. Thank you for your honesty and straightforwardness. I wish more health care and mental health practitioners had the courage to speak to the new reality being imposed on all of us with questionable and tangential science.

    Liked by 3 people

  18. Reblogged this on Violet Dust.

    Like

  19. I completely appreciate your honesty, and I get it. I lived with a mtf for 4 years, and was amazed at what I was seeing and hearing, the multiple personalities that I counted were up to (5) and that was on the female side. On the male side there was always only (1) personality. I never knew who I was coming home to, sometimes the personality would change from one to another right in front of me, it was the little girl child that I would worry about, and then the bitchy mean girl would come out and take over. Very confusing and strange to watch. May I also add that this person was also non sexual or a-sexual.
    If you have any questions feel free to ask

    Liked by 3 people

  20. So I’m an mtf and I just wanted to comment here because I rarely see any thoughtful responses to posts like this. I’ll just start by saying that I transitioned in my 20’s and am now in my 30’s. I have a masters degree, work in the medical field and I’m active in my community. The reason I’m sharing this is to highlight the fact that I am not crazy, and in fact I’m happy and fairly successful. I know many other trans women who are as well. Now, have I met transwomen who seem mentally unstable? Have I met transwomen who possess pretty aggressively masculine demeanors? Have I met transwomen who wear 6inch heels and prance around in poofy dresses? Yes, yes and yes. And have these people made me uncomfortable at times? Absolutely. I just can’t get my head around the motivations of some, but we are not all like that. Unfortunately we are not the ones obsessively (and yes sometimes loudly and aggressively) commenting on blog posts because we have our lives to live.

    I also want to say that while I am grateful for the support of the doctors and others in the medical community who I have worked with, I do agree that the motivations for seeking to transition need to be carefully explored before that transition is begun. I also agree that the medical establishment has not done a good job in some cases. Understanding whether underlying mental health issues are coming into play is just so basic, and overlooking any issues is a disservice to the patient. Additionally I am very wary of allowing children to medically transition. I am all for kids being able to explore their gender identity but allowing any procedures that permanently alter the body make me very uneasy.

    In reading through comments on posts like this I certainly see some things I disagree with. One thing I don’t understand is the fact that not that long ago our society characterized homosexuality as a mental illness. And not that long ago gays and lesbians were told to suck it up, make due wwith what God gave them and have sex with someone of the opposite sex. As we as a society those attitudes have changed. Why are these same things being said about trans people, namely that we are mentally ill, or that we should just accept that our gender is determined by our biological sex? How is it any different?

    And there is this debate over whether gender identity is innate or not. Well I remember when there was a lot of debate over whether homosexuality was a trait someone was born with or not, and science seems to say that biological and environmental factors can be at play. But somehow in regards to homosexuality it doesn’t seem to matter as much anymore as society has become more accepting. So why does it matter whether trans people gender identity is innate or not? Why would it not being innate but instead informed by environmental factors diminish its realness?

    Finally, it seems that trans people are often criticized for conforming to the gender binary, as in switching from one side to the other. The is though, is that 95+% of people conform to the gender binary. Why is it worse when trans people do? Trans people are subjected to the same social conditioning and societal pressures as everyone else, so why would they be expected to not fall into the gender binary that majority of others do.

    Anyway, those are just some of my thoughts. I’m sure much of this will fall on deaf ears but I still felt the need to share.

    Like

    • No one is saying that your “gender is determined by [y]our biological sex”, just that you can’t change your sex, which is biological, and that you can do whatever you want with gender, dress, present however you want. No matter what you do you are not the other sex but the one OBSERVED at birth. The problem arises when you insist that you REALLY are the other sex. This has consequences for real people, mostly women. Real programs are gutted, real sex-segregated spaces are destroyed, real women are endangered, real women are forced to compete, and lose, to men in sports, etc,etc. So you see, it’s not the same argument as the rightwing anti-gay argument at all. No one particularly cares if you personally decide to shoot yourself up with toxic and dangerous pharmaceuticals or endanger your physical integrity by having dangerous (pricey procedures). It may be sad (or not) but none of my business what you do with your life. It’s not at all about self-righteous or religious moral outrage, at least not from the feminist angle.

      As far as gender-identity, bear in mind that identity is not the real thing. You can identify as whatever suits your fancy but that does not make you so. Do you think bio-women “identify” as women? Bio women are identified as women, which is entirely different. So it seems to me that how you identify, or choose to identify, is really neither here nor there because all of the above still applies. Innate or not is NOT as relevant as some would think. The only reason the discussion is even taking place is because trans rides the coattails of LGB and it is seen as a necessary discussion for a desired outcome.

      Trans really encourages people to pick one of two flavors even though queer theory holds that there are gazillion genders. Bio males who transition always default to the I-am-a-woman camp. And this is hailed as “brave” instead of what it really is, an attempt to deprive real women of our spaces and the small foothold we’ve carved out for ourselves over many, many years of struggle. Brave would be having the courage to live life as a gender non-conforming man. What’s so horrible about being a femmy guy? It’s a perfectly legitimate way to do male and one that would REALLY upset the gender apple cart and actually be liberating for humanity. Transition only reinforces stereotypes and confirms that there are only two legitimate forms of “gender” expression, the stereotype assigned to the men class and the stereotype assigned to the woman class. If you want to be revolutionary, work to change male rape culture and to legitimize different ways to be male. Male rape-culture is learned and it can be unlearned.

      Liked by 7 people

    • I am a radical feminist and appreciate reading such a thoughtful reply; I tend to avoid comment sections because the tone from both sides can so quickly shut down any legitimate conversation.

      On a human level, it is really nice to hear of a trans individual who is thriving and may it be so for everyone. And I do hope other readers keep in mind that the encounters of one doctor can hardly sum up an entire population.

      But specifically, I wanted to note that one of the issues you raise is an ongoing point of confusion for me: “not that long ago our society characterized homosexuality as a mental illness … those attitudes have changed. Why are these same things being said about trans people, namely that we are mentally ill, or that we should just accept that our gender is determined by our biological sex? How is it any different?”

      The fact is, that is what I hear from the trans community: That there is a mental illness called gender dysphoria, that can never be cured but only managed, and that the preferred management is often pharmaceutical drugs or surgery.

      This seems fundamentally different from gay rights activists arguing that homosexuality is healthy and in no way disordered (and in fact the disease is heternormativity and the implicit violence therein).

      As someone who is critical of the entire psychiatric model and understanding of mental health as exists in western medicine, it is baseline difficult to understand that mental illness is an “identity” and that pharmaceutical drugs and surgery are a solution.

      I would welcome any other impressions on this.

      Liked by 2 people

  21. I was always a bit nervous going to the GID, as it was full of people like you describe. Scary people, with body language that spoke of mental issues, and left me not wanting to make eye contact. It concerned me, was i like them? I prayed not.
    Going for surgery was worse. There was one woman there that settled my discomfort a little, but the place was full of scary people, supposedly women, bragging about the depth of their vaginas and telling tall tales about their sexual exploits. I’d done a lot of soul searching before arriving, and it was only that one woman’s words “you are here now, trust the decisions you have made” that helped me not flee the fear i carried that i was just like the men in surgical drag i saw around me.
    12 years later, I’m glad i did it, glad i was true to the knowledge that had been with me since i was 4. Surgical complications aside (now corrected), I live a contented and whole life, full of love and purpose. I no longer have gender identity issues, and i no longer suffer from suicidal depression. I’m just me, for better or for worse. So, SRS worked as a treatment for my GID. I no longer feel like i am deceiving my partners, although they might not appreciate my history. Do i think the current equanimity could have been achieved without surgery? No. i hated having that thing strapped to my body. I think that i’d be dead by now.
    Should i have persevered anyway? Struggled to be as i am now, but a man? I’ve thought about it – being a woman is not easy, sexism is really really annoying, and i’ve considered cross-dressing and pretending to be male so that i wouldn’t be talked down to or over by men, but that would be living a lie. But no. I might regret it, if i have to re-incarnate as male again for another attempt.
    Still, it is scary to see what is going on in the TG world now. The concept of a gender spectrum, the nonsensical divorcing of gender from the biological, the idea of a ‘female’ penis. None of it is consistent, it is a minsogynst nightmare.
    I worry that the few people who need SRS, like myself, or that woman i met at the hospital, will be denied the treatment they need, lost by the takeover of a truly marginal section of women by fetishistic males, confusing gender roles with the physical.
    I find myself being called a ‘terf’, and agreeing with nearly all they say, knowing that i’m rejected and excluded by that same group.

    Like

Trackbacks

  1. Track back: […] Kathy Mandigo who wrote the essay, My Disservice to My Transgender Patients is interviewed on TRTV SHOW REAL […]

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