Medicine and biology apply to transgender people, as much as everyone else

trans medicine

I often hear trans activists claim that transgender people are so special, the entire field of medicine “knows nothing about them” and on that account they dismiss all medical opinion that doesn’t validate their demands. As a doctor, I disagree.

Humans are largely the same, medically speaking, even though there are some more or less obvious and important differences in anatomy and physiology between individuals.

Say your heart points to the wrong side of your chest (dextrocardia). This is rare but important. Or your ulnar nerve runs in the wrong position – rare and not very important unless you throw a ball a lot. Or perhaps your pancreas doesn’t produce insulin (Type I diabetes), which is common and very important.

Sometimes 99% of humans can be divided into two groups based on one important difference, for example, whether they contribute to human reproduction by producing ova (women) or sperm (men). Reproduction is an example of extremely common and important function of the human body which enables survival of our species, just like successful management of blood glucose enables survival of an individual.

Situations in which something goes wrong in the development of an individual human, so they don’t produce gametes (ova or sperm), or their pancreatic cells fail to produce insulin, are considered abnormalities, and medicine studies them in order to help, if possible.

Abnormalities aren’t “variations of normal” because they prevent or limit normal function. Type I diabetics don’t have “alternative yet normal glucose metabolisms”, nor can they *identify* their way into managing glucose without insulin.

Some abnormalities interfere with life more than others. For example, not being able to conceive a child isn’t life threatening to anyone other than that potential child, whose existence isn’t assured anyway due to incredible complexity of conception, gene combination and development. Which doesn’t mean people who can’t conceive won’t be upset about it.

I like to think about body and mind as a continuum, where the body can exist without the mind but so far, it’s not possible for the mind to exist without the body. Literally everything that happens to our bodies registers in the mind somehow, whether we are aware of it at the time or not.

This is why I love psychiatry. It’s a branch of medicine that focuses on the mind while being mindful of the body, while a lot of physical medicine and especially surgery focuses almost myopically on the body alone. “Refer to psych” is a common throwaway comment applied to difficult patients.

Some of the most notoriously difficult patients from a doctor’s point of view are those who are paranoid, deluded or have personality disorders, all of which can not only make their medical problem worse, they can create the problem, or an appearance of it.

Depression is sometimes reported as a headache, delusion as unshakeable belief that body parts need to be amputated, hallucination as repeated attempts to remove alien micro chip from one’s abdomen, anxiety as hypochondria, panic attack as heart attack.

Medical doctors naturally pursue physical diagnosis at first, because physical diagnoses often have a cure. But if it becomes clear patient’s symptoms are psychosomatic, ie. rooted in psychological abnormality rather than a physical one, and the doctors are seeing these patients over time, they can start to feel “heart-sink” because of patient’s distress and doctor’s inability to help them.

What a lot of people don’t know is that most doctors are terrible optimists. We are reluctant to give bad prognosis or simply give up. This is why we keep referring difficult patients to each other, hoping that the expert in a different field of medicine might have a solution. And often they do. But when they don’t, the patients inevitably end up being psychiatry’s problem. And that’s ok, that’s what psychiatrists are here for, it’s why they are trained as doctors first, so they can keep looking after the mind, while remaining mindful of the body.

It’s not rare for a psychiatrist to diagnose a medical illness, especially if it’s rare and the patient hasn’t been to too many other specialists. For medicine to work like this, there have to be many more similarities between individual patients, than differences.

We don’t learn many unique medicines. I don’t swap between huge bodies of knowledge depending on whether a man or a woman or a trans person walks through the door. Learning myriad small, more or less important ways our bodies can be different IS medicine.

Sometimes tiny differences can be incompatible with life. Sometimes much bigger differences, like a limb missing, can be managed more easily. What you see isn’t always what you get. Ideas and treatments change, but bodies have been the same for millions of years.

Doctors and vets speak about mammals with comparable knowledge, this is how much all mammalian bodies resemble each other, let alone within the same species. In fact, vets are incredibly knowledgeable although their patients don’t have the same expectations as human patients do.

Human medicine is often about managing expectations, and this is where approch that largely ignores the mind, met with unwarranted optimism, can struggle. Transgender surgery, for example. I heard many gender-reassignment surgeons say that they “construct genitals”.

Truth is, they’d fail an exam in medical school if they claimed that surgical cavity is the same as embryonologically developed vagina. That artificially created phallus that has to be inflated through a pump and lacks urethra is the same as a penis. And yet they say it all the time.

They also claim that they are changing people’s sex, knowing full well that they aren’t making men capable of producing ova, and vice versa. They say it because they are enamoured with their own skills, a bit narcissistic, and they genuinely want to help their patients.

Even most blunt and practical doctors are very emphatic, and sometmes this manifests in downplaying negative outcomes, and saying things in a way that won’t upset the patients. They don’t like confrontation and have an irrational belief that all will be well. When things go wrong, they tend to blame, hide or refer elsewhere.

This is broadly speaking how it came to be that healthy bodies are mutilated medically in order to “cure” feelings, and how the evidence that indicates that outcomes don’t justify the risks didn’t stop this practice, it expanded it. To children.

“If we could only get to them young enough, the outcomes would be better” gender specialists say, swayed by how “passable” an androgynous teenager looks in gender non-conforming presentation. It’s a bit like the power of advertising.

But that teen will grow up, and if their bodies were medically and surgically mutilated, they’ll also have chronic medical conditions as a consequence.

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They can do more treatments to make it look or work better they say. But do they stop to think what they are doing?

I can’t imagine how hard it is for someone who is desperately unhappy and confused about their body, to decide to live with all the consequences of doctors trying to make their bodies look like something they are not. To think they’re not being told the whole truth is terrifying.

It’s not that trans people are so different, they are being failed by treatments with poor outcomes, and this is worsening due to aggressive campaigns for gender self-identification which are demanding that we forget all we know about medicine, human body and psychology and reduce medical care of transgender people to unquestioning affirmation of inner feelings and ever faster and earlier access to drugs and surgery.

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There might not be a cure for people feeling like they were born “in the wrong body”. Or the cure might lie in curing society of its prejudices. Or maybe there will come a time when we’ll find a way to rebuild individuals from scratch, change the chromosomes in every cell in their body, alter biochemical processes and erase all effects socialisation and experience had on our brains and bodies. I can imagine an ethical minefield that would have to be navigated in order to justify this, but that’s science fiction not our reality.

Meanwhile we must try to alleviate suffering. Transgendered patients may not be happy with doctors, but we need to be there for them anyway. We need to be honest about treatment options, possible complications and outcomes and more than anything we need to be there for them when they are unhappy, angry and sad. We must do all this without causing additional harm.

And before you repeat a mindless catchphrase, ask yourself: Is a schizophrenic born “in the wrong body”? A child with leukemia? A woman struggling with body dysphoria in a pornified world? If you pull that thread, the whole yarn unravels.

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