Don’t demonise doctors for treating gender identity disorder

Some people experience a profound discomfort with their biological sex. David Castillo

Imagine yourself as a doctor consulting with a child who is experiencing profound discomfort. At times, the parents inform you, the child’s profound discomfort escalates, manifesting in profound distress that leads to self-harming behaviour.

Imagine, now, that the child knows exactly what is causing their discomfort and that you can facilitate that treatment, with the full support of the child’s parents. No brainer, right? But what if the child is experiencing gender dysphoria, a “profound discomfort with (one’s) biological sex and a strong identification with the gender of the opposite sex”?

Recent research highlighting an increase in the number of children referred to a gender dysphoria clinic in Melbourne brings to light some of the complex, highly charged issues that emerge when medicine steps into this contested cultural space.

Sex, gender and gender dysphoria

To understand gender dysphoria, it is important to first understand the difference between gender and sex. Sex pertains to the biological categories of male and female. Males and females are distinct from one another in regards to a range of factors including sex chromosomes (XY or XX), hormones and sex organs.

Gender, on the other hand, is a more slippery concept. It refers to the categories of man or woman and boy or girl. Gender is typically viewed as a “natural” expression of sex; males are “naturally” manly (masculine) and females are “naturally” womanly (feminine).

But gender can also be understood as a social construct. According to this view, males display masculine characteristics (competitiveness, non-emotionality) and females display feminine characteristics (sensitivity, passivity) because of cultural expectations. These cultural expectations are often referred to as “gender norms”.

The slipperiness of gender means that gender dysphoria is a highly-charged issue. If gender is a social construct, could it be that the “profound discomfort” experienced by people with gender dysphoria is the result of restrictive cultural expectations – that males will feel (and act) like men and females will feel (and act) like women – rather than the consequence of a medical condition? And could it be that by treating people with gender dysphoria doctors are responding to cultural expectations rather treating a real medical condition?

The experiences of many people with gender dysphoria would suggest that the cultural expectation hypothesis is bunkum or, at best, overly simplistic. The idea that they are responding to cultural expectations undermines the personal, intimate – and typically very distressing – nature of their experience.

The role of doctors

Discussions about the role of doctors in treating gender dysphoria often present them as being enforcers of culturally acceptable gender norms. According to this argument, by changing a person’s physical body (such as a male-born person who undergoes sex reassignment surgery) to “match” their gender (so that the male-born person then has a body that “matches” their experience of themself as a woman), doctors are reinforcing the idea that males cannot (or should not) feel or act like women and females cannot (or should not) feel or act like men.

There are a number of problems with this argument. To begin with, adults with gender dysphoria seek out treatment for their condition. They’re not plucked from a crowd for failing to live up to “gender standards”.

The research mentioned at the start of this article suggests that children (with the help of their parents) also seek out the services of gender identity clinics.

Johnny is not plucked from the playground because he likes playing with My Little Pony and forced to undergo gender transition. Rather, the research indicates that these children and their parents go to great lengths to consult with doctors at gender identity clinics. So how then can doctors be the enforcers of gender norms if it is patients who seek and request that treatment?

But then again, just because some people seek out treatment for gender dysphoria, doesn’t mean they’re not influenced by gender norms. It could be that people who experience gender identify disorder somehow internalise cultural expectations of gender and as a result, come to understand themselves as having a medical condition that requires treatment.

The problem with this argument is that it suggests that the people who seek out treatment for gender dysphoria are cultural “dupes” – the victims of some kind of “gender conspiracy”. When it comes to children with gender dysphoria, this argument takes us back to an era when children’s voices and self-described experiences were viewed as unreliable and untrustworthy. It suggests that children cannot speak for themselves and do not know themselves and their bodies.

When medical treatment raises questions

Research in Melbourne suggests only a small number of children currently seek treatment for gender dysphoria. But the issues that emerge as a result of the treatment of this condition raise questions that apply to a much broader audience.

When do children know their own body and understand the meaning and significance of their experiences? How can we have debates about contested medical treatments when one side relegates patients to the role of cultural dupes and demonises the doctors who try to help them? And most importantly, how do we give voice to people - especially children - whose experiences challenge our own beliefs?