Debbie says:

Andrea Becker’s article, These nonbinary patients were seeking trans health care. But in a binary system, they felt ‘invalidated.’, published at The Lily, feels all too familiar. In 1994, The New Yorker published one of the first popular articles about trans men (behind a registration wall). One thing I remember clearly from that article is a trans man righteously complaining that he couldn’t convince his (male) bottom surgery doctor that he didn’t want a large penis. The doctor’s preconceptions were stronger than the patient’s preferences.

I suspect that this is a problem trans men run into much less frequently now, because there are many trans men, and there are many fine trans care clinics. But the preconceptions and exclusions have, according to Becker, shifted to treatment of nonbinary people. Here Becker (a medical sociologist) quotes Chase Weaverling, a 35-year-old enby:

“I get back there, and it’s not a conversation at all,” they said. “The nurse is telling me what’s going to happen and how I have to do things. The assumption was, you’re here for [testosterone], therefore you’re a trans man, therefore you want maximum testosterone and effects, and that’s what we’re going to do.” …

The nurse not only assumed Weaverling was a trans man, but also bypassed all of their questions about starting slowly with a low dose of testosterone to see if they liked the changes, and instead prescribed a rigid plan that they could not customize,

The protocols are known, the assumptions are fully in place, and despite the fact that one million Americans identify as nonbinary (a number that surprised me), customization is apparently not the order of the day:

while trans men and women might want full doses of hormone replacement therapy and aspire to complete all of the available steps of transgender care, nonbinary patients might want surgery without hormones. Others, such as Weaverling, may want to experiment with microdoses of hormones for more subtle changes.

One of the problems seems to be that trans people still have to defend their own need for care:

In the current trans medical model, the onus is on patients to prove they are “transgender enough” to qualify for gender-affirming care. As proof, providers often expect descriptions of gender and bodily and social discomfort that fit the accepted diagnostic criteria. If the narrative matches these characteristics, patients are diagnosed with gender dysphoria. This psychological diagnosis then serves as a green light for subsequent trans medicine, provided the person follows the requisite steps in the correct order.

A nonbinary person, on the extra hand, might not match all (or any) of the “accepted diagnostic criteria.” Any medical model that relies on intense discomfort for a diagnosis is already setting itself up to be rigid, and to exclude even a subset of the people it’s intended for. So if we then add a different group of people in related situations that don’t fit the exclusionary framework, we are substantially increasing the percentage of people who don’t get what they need, because they don’t fit in the predesigned box.

I never expected to see or hear the word “transnormativity,” but it is apparently in common use in these circumstances. I find this intensely distressing, and not at all surprising.

Becker does provide some hope for the future:

Experts say standards of care must recognize that sex and gender are both spectrums and there is no “right way” to engage with trans medicine. As part of this, providers can move toward a patient-centered approach to gender-affirming health care.

For [Evan] Vipond, [a PhD candidate in gender, feminist and women’s studies at York University], this approach hinges on the idea that “each patient’s needs and desires in regard to transitioning are different and equally valid.”

And there’s a well-understood solution, used in many medical situations every day:

In an informed consent model, providers grant patients all of the available information regarding risks and benefits — empowering the patient to make their own decisions about a medical procedure, whether that’s hormone therapy or surgery. This takes concerns about a patient regretting a procedure out of the hands of a provider and allows patients to be an active participant in their care.

Experts agree that informed consent for trans health would help reduce the stigma attached to medical transition and trans identities and make gender-affirming care more accessible to those who need it.

Informed consent is an excellent approach. At the same time, I will never stop wishing that we could just believe people when they tell us what they need, whether it’s gender-related or not. I can imagine a world where we don’t need an “informed consent model” because as a society and culture we are committed to taking people seriously and working with each other so that everyone’s preferences are respected and we all get what we need.

Utopian? Moi?

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